Surgery Fee Schedule - Labor & Industries (L&I ... · Professional Services Fee Schedule Surgery...

Professional Services Fee Schedule

Surgery

Effective July 1, 2017

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Surgery Fees

Effective for Dates of Service on or After

July 1, 2017


CPT® only are copyright 2016 American Medical Association. All rights reserved. Refer to Field Key for definitions Surgery


Surgery


Copyright InformationPhysicians’ Current Procedural Terminology (CPT®) five-digit codes, descriptions, and other data only are copyright 2016 American Medical Association. All Rights Reserved. CPT® is a registered trademark of the American Medical Association.No fee schedules, basic units, relative values or related listings are included in CPT.AMA does not directly or indirectly practice medicine or dispense medical services.AMA assumes no liability for data contained or not contained herein.

This document is also on the department’s Internet web site at http://feeschedules.lni.wa.gov/. Updates to this manual can be found under ‘Updates and Corrections’ tab on the department’s Internet web site athttp://feeschedules.lni.wa.gov/Updates to this manual are also announced on the Medical Provider e-News listserv. Individuals may join the listserv at http://www.lni.wa.gov/Main/Listservs/Provider.asp.


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Surgery


SURGERY FEES

Not Covered Procedure code is not covered.

DOLLAR VALUE

FACILITY SETTING

This column indicates the:

• Maximum dollar amount for covered services

provided in a facility setting, or

• Pricing method for the procedure code, or

• Coverage status for the procedure code.

Dollar Value Maximum dollar amount payable for covered services.Bundled Bundled code, not separately payable.

Hosp. Only Procedure code for hospital outpatient use only.

Contracted

Contracted service. Payable only to department’s contracted vendor

for State Fund claims. Payable to providers treating Self-Insured

injured workers.

Maximum dollar amount payable for covered services.

Not Covered

ABBREVIATED

DESCRIPTION

Abbreviated HCPCS code description. No

descriptions are provided for CPT

codes.

Abbreviated description for reference purposes only. Refer to a 2017

CPT or HCPCS code book for complete code descriptions.

Bundled Bundled code, not separately payable.

DOLLAR VALUE

NON-FACILITY SETTING

This column indicates the:

• Maximum dollar amount for covered services

provided in a non-facility setting, or

• Pricing method for the procedure code, or

• Coverage status for the procedure code.

By Report Service paid on a “by report” basis.

Procedure code is not covered.

Contracted



injured workers.

Facility Only Procedure code for facility outpatient use only.

FIELD KEY: Column Title Column Description

2017 CPT or HCPCS code 2017 CPT

or HCPCS code

Column Values Value Definitions

By Report Service paid on a “by report” basis.

Dollar Value

CPT CODE/

HCPCS CODE



Surgery


POST OP

(-55)

Postoperative Percentage

(Modifier –55)Percent

The percent of the total global surgery dollar value that is allowed

when modifier -55 is billed.

INTRA OP

(-54)

Intraoperative Percentage



when modifier -54 is billed.

Modifiers -26 and -TC are not valid . Stand alone code for the

technical component of a diagnostic test. An associated code

describes the professional component of the diagnostic test or the

global procedure (professional and technical components).

PRE OP

(-56)

Preoperative Percentage



when modifier –56 is billed.

FOL UP Follow-up Days for Global Surgery NumberThe number of days following surgery during which charges for

normal postoperative care are bundled in the global surgery fee.

Field Key: Surgery (continued)Column Title Column Description Column Values Value Definitions

PCTC

(26/TC)

Professional and Technical Component

(Modifiers –26 and –TC)

This field identifies whether professional and

technical component modifiers (-26/-TC) are

valid with the procedure code.

0Modifiers -26 and -TC are not valid . The procedure is for physician

services only; the concept of PC/TC does not apply

1Modifiers -26 and -TC are valid . Diagnostic test or radiology

service which has both a professional and technical component.

2


professional component of a diagnostic test. An associated code

describes the technical component of the diagnostic test or the

global procedure (professional and technical components).

3



Surgery


PCTC

(26/TC)

(Continued)

Field Key: Surgery (continued)

Column Title Column Description Column Values Value Definitions

Professional and Technical Component

(Modifiers –26 and –TC)

This field identifies whether professional and

technical component modifiers (-26/-TC) are

valid with the procedure code.

4

This indicator is not currently in use.

8

Professional component of a clinical laboratory code; payable only if

the physician interprets an abnormal smear for a hospital inpatient.

No -TC modifier billing is recognized; payment for the underlying

clinical laboratory test is made to the hospital. Not payable when

furnished to hospital outpatients or non-hospital patients.

9Modifiers -26 and -TC are not valid . Concept of a

professional/technical component split does not apply.

6

Modifier -TC is not valid ; modifier -26 may be valid . Clinical

laboratory or other service for which separate payment for

interpretations by laboratory physicians or other physicians may be

made.

7


global procedure for a diagnostic test. Associated codes describe

the professional and technical components of the diagnostic test.

5

Modifiers -26 and -TC are not valid . Covered service incident to a

physician’s service when provided by auxiliary personnel employed

by and working under the direct supervision of the physician. This

service not payable when provided to hospital inpatients or

outpatients.



Surgery


Modifier -51 is valid . Standard multiple surgery payment policy

applies (100%, 50%, 50%, 50%, 50%).

3

Modifier -51 may be valid . Multiple endoscopic procedures

payment policy applies if this service is billed with another

endoscopy in the same family.

MSI

Multiple Surgery Indicator

(Modifier –51)

This field indicates whether multiple surgery

payment rules apply to the service.

0

4 This indicator is not currently in use.

9Modifier -51 is not valid . Concept of multiple surgery does not

apply.

5


Modifier -51 is not valid . Payment adjustment rules for multiple

surgeries do not apply.

1 This indicator is not currently in use.

This indicator is not currently in use.


2



Surgery


Column Title Column Description

2

Modifier -50 is not valid . Payment adjustment for bilateral

procedures does not apply. Procedures in this category include

services for which the code descriptor specifically states that the

procedure is bilateral; procedures that are usually performed as

bilateral procedures; or procedures for which the code descriptor

indicates the procedures may be performed either unilaterally or

bilaterally.


9Modifier -50 is not valid . Concept of bilateral surgery does not

apply.

BSI

Bilateral Surgery Indicator

(Modifier –50)

This field indicates whether the procedure is

subject to a payment adjustment for bilateral

surgery.

0Modifier -50 is not valid . Payment adjustment rule for bilateral

surgery does not apply.

1Modifier -50 is valid . Payment adjustment for bilateral procedures

(150%) applies to this procedure.

3

Modifier -50 is not valid . Payment adjustment for bilateral

procedure does not apply. This is a radiology procedure which is not

subject to payment rules for bilateral surgeries.

Column Values Value Definitions



Surgery


Modifier -62 is not valid with this procedure. Concept of co-

surgeons does not apply.

9 Modifiers -80, -81 and -82 are not valid . Concept does not apply.

9

ASI

Assistant Surgeon Indicator

(Modifiers –80, -81, -82)

This field indicates whether or not an assistant

surgeon may be paid for the procedure.

0

Modifiers -80, -81 and -82 are not valid under normal situations .

Assistant at surgery is not usually paid for this procedure.

Supporting documentation is necessary to establish medical

necessity.

1Modifiers -80, -81 and -82 are not valid. Assistant at surgery may

not be paid for this procedure.

Modifier -62 is not valid under normal situations . Supporting

documentation is required to establish medical necessity of two

surgeons.

2

Modifier -62 is valid . Co-surgeons may be paid for this procedure.

Supporting documentation is not required if two specialty

requirement is met.

CSI

Co-surgeons Indicator

(Modifier –62)

This field indicates whether or not co-surgeons

may be paid for the procedure.

2Modifiers -80, -81 and -82 are valid . Assistant at surgery may be

paid.


0 Modifier -62 is not valid . Co-surgeons not permitted.

1




Surgery


N No fee or RVUs available, code paid by report.

O For hospital outpatient use only.

FSI

Fee Schedule Indicator

This column indicates the payment status for

the procedure code.

C



injured workers.

DDrug fee based on Average Wholesale Price (AWP) or Average

Average Wholesale Price (AAWP).

T Tracking code

X Non-covered code

R RBRVS fee

S State Rate

F Flat fee developed by the department

L Clinical lab fee

ENDO BASE Endoscopy Base Code Code number

This column contains the endoscopic base code for procedure

codes that are part of an endoscopy family. The Multiple Surgery

Indicator for procedures in an endoscopy family is 3.

B Bundled code, not separately payable.



TSI

Team Surgeons Indicator

(Modifier -66)

This field indicates whether or not team

surgeons may be paid for the procedure.

0 Modifier -66 is not valid . Team surgeons not permitted.

1

Modifier -66 is not valid under normal situations . Team surgeons

may be payable. Supporting documentation is required to establish

medical necessity of a team.

2 Modifier -66 is valid. Team surgeons permitted.

9 Modifier -66 is not valid . Concept of team surgery does not apply.

Prior authorization and UR requiredPRIOR AUTH

Prior authorization indicator

This column indicates whether prior authorization

and utilization review is required.

Y Prior authorization required

Y-UR



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH

10021 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X


10030 $ 1,297.26 $ 275.77 0 0% 0% 0% 9 2 9 0 0 0 R Y



10040 $ 185.32 $ 161.29 10 10% 80% 10% 0 2 0 1 0 0 R Y

10060 $ 215.68 $ 179.00 10 10% 80% 10% 0 2 0 1 0 0 R

10061 $ 376.97 $ 328.27 10 10% 80% 10% 0 2 0 1 0 0 R

10080 $ 330.80 $ 188.49 10 10% 80% 10% 0 2 0 1 0 0 R Y

10081 $ 493.35 $ 308.03 10 10% 80% 10% 0 2 0 1 0 0 R Y

10120 $ 281.46 $ 189.75 10 10% 80% 10% 0 2 0 1 0 0 R

10121 $ 500.94 $ 337.12 10 10% 80% 10% 0 2 0 1 0 0 R

10140 $ 299.81 $ 216.32 10 10% 80% 10% 0 2 0 1 0 0 R

10160 $ 237.82 $ 175.20 10 10% 80% 10% 0 2 0 1 0 0 R

10180 $ 448.44 $ 323.21 10 10% 80% 10% 0 2 0 1 0 0 R

11000 $ 99.94 $ 51.87 0 0% 0% 0% 0 2 0 1 0 0 R

11001 $ 39.22 $ 25.93 0 0% 0% 0% 0 0 0 1 0 0 R

11004 $ 1,040.46 $ 1,040.46 0 0% 0% 0% 0 2 0 1 0 0 R

11005 $ 1,397.19 $ 1,397.19 0 0% 0% 0% 0 0 0 0 0 0 R

11006 $ 1,265.00 $ 1,265.00 0 0% 0% 0% 0 2 0 1 0 0 R

11008 $ 490.82 $ 490.82 0 0% 0% 0% 0 0 0 0 0 0 R

11010 $ 926.61 $ 515.49 10 10% 80% 10% 0 2 2 1 0 0 R

11011 $ 981.01 $ 540.16 0 0% 0% 0% 0 2 2 1 0 0 R

11012 $ 1,297.26 $ 768.49 0 0% 0% 0% 0 2 2 1 0 0 R

11042 $ 214.42 $ 112.59 0 0% 0% 0% 0 2 0 1 0 0 R

11043 $ 415.55 $ 282.10 0 0% 0% 0% 0 2 0 1 0 0 R

11044 $ 569.25 $ 416.19 0 0% 0% 0% 0 2 0 1 0 0 R

11045 $ 74.00 $ 46.81 0 0% 0% 0% 0 0 0 0 0 0 R

11046 $ 132.19 $ 101.20 0 0% 0% 0% 0 0 0 0 0 0 R

11047 $ 223.91 $ 179.00 0 0% 0% 0% 0 0 0 0 0 0 R

11055 $ 88.55 $ 29.10 0 0% 0% 0% 0 2 0 1 0 0 R

11056 $ 108.16 $ 41.11 0 0% 0% 0% 0 2 0 1 0 0 R

11057 $ 120.81 $ 53.76 0 0% 0% 0% 0 2 0 1 0 0 R

11100 $ 190.38 $ 89.18 0 0% 0% 0% 0 2 0 1 0 0 R

11101 $ 59.46 $ 45.54 0 0% 0% 0% 0 0 0 1 0 0 R

11200 $ 162.55 $ 135.99 10 10% 80% 10% 0 2 0 1 0 0 R Y

11201 $ 34.16 $ 30.36 0 0% 0% 0% 0 0 0 1 0 0 R Y

11300 $ 181.53 $ 64.52 0 0% 0% 0% 0 2 9 0 0 0 R

11301 $ 222.64 $ 98.04 0 0% 0% 0% 0 2 9 0 0 0 R

11302 $ 262.49 $ 115.12 0 0% 0% 0% 0 2 9 0 0 0 R

11303 $ 289.05 $ 135.36 0 0% 0% 0% 0 2 9 0 0 0 R

11305 $ 183.43 $ 71.47 0 0% 0% 0% 0 2 9 0 0 0 R

11306 $ 226.44 $ 94.88 0 0% 0% 0% 0 2 9 0 0 0 R

11307 $ 265.65 $ 122.07 0 0% 0% 0% 0 2 9 0 0 0 R

11308 $ 278.30 $ 134.09 0 0% 0% 0% 0 2 9 0 0 0 R

Surgery FeesDOLLAR VALUE MODIFIERS

NON-FACILITY

SETTING FACILITY SETTING



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


11310 $ 211.26 $ 86.65 0 0% 0% 0% 0 2 9 0 0 0 R

11311 $ 203.67 $ 119.54 0 0% 0% 0% 0 2 9 0 0 0 R

11312 $ 296.64 $ 142.31 0 0% 0% 0% 0 2 9 0 0 0 R

11313 $ 342.82 $ 182.79 0 0% 0% 0% 0 2 9 0 0 0 R

11400 $ 228.97 $ 148.64 10 10% 80% 10% 0 2 0 1 0 0 R

11401 $ 273.87 $ 190.38 10 10% 80% 10% 0 2 0 1 0 0 R

11402 $ 304.87 $ 208.73 10 10% 80% 10% 0 2 0 1 0 0 R

11403 $ 351.04 $ 269.45 10 10% 80% 10% 0 2 0 1 0 0 R

11404 $ 397.84 $ 295.38 10 10% 80% 10% 0 2 0 1 0 0 R

11406 $ 568.62 $ 446.55 10 10% 80% 10% 0 2 0 1 0 0 R

11420 $ 225.80 $ 150.54 10 10% 80% 10% 0 2 0 1 0 0 R

11421 $ 287.16 $ 201.77 10 10% 80% 10% 0 2 0 1 0 0 R

11422 $ 321.31 $ 248.57 10 10% 80% 10% 0 2 0 1 0 0 R

11423 $ 368.12 $ 286.52 10 10% 80% 10% 0 2 0 1 0 0 R

11424 $ 425.67 $ 327.64 10 10% 80% 10% 0 2 0 1 0 0 R

11426 $ 604.04 $ 497.78 10 10% 80% 10% 0 2 0 1 0 0 R

11440 $ 247.94 $ 189.75 10 10% 80% 10% 0 2 0 1 0 0 R

11441 $ 308.03 $ 240.35 10 10% 80% 10% 0 2 0 1 0 0 R

11442 $ 344.08 $ 266.28 10 10% 80% 10% 0 2 0 1 0 0 R

11443 $ 408.60 $ 325.74 10 10% 80% 10% 0 2 0 1 0 0 R

11444 $ 512.33 $ 413.66 10 10% 80% 10% 0 2 0 1 0 0 R

11446 $ 709.03 $ 592.65 10 10% 80% 10% 0 2 0 1 0 0 R

11450 $ 697.65 $ 457.93 90 10% 71% 19% 0 2 1 1 0 0 R

11451 $ 886.77 $ 588.86 90 10% 71% 19% 0 2 1 0 0 0 R

11462 $ 683.10 $ 438.96 90 10% 71% 19% 0 2 1 0 0 0 R

11463 $ 900.05 $ 593.92 90 10% 71% 19% 0 2 1 0 0 0 R

11470 $ 752.04 $ 509.16 90 10% 71% 19% 0 2 0 1 0 0 R

11471 $ 932.31 $ 634.40 90 10% 71% 19% 0 2 0 0 0 0 R

11600 $ 354.20 $ 218.85 10 10% 80% 10% 0 2 0 1 0 0 R Y

11601 $ 419.98 $ 273.24 10 10% 80% 10% 0 2 0 1 0 0 R Y

11602 $ 455.40 $ 299.81 10 10% 80% 10% 0 2 0 1 0 0 R Y

11603 $ 519.28 $ 358.63 10 10% 80% 10% 0 2 0 1 0 0 R Y

11604 $ 576.21 $ 393.42 10 10% 80% 10% 0 2 0 1 0 0 R Y

11606 $ 819.72 $ 581.27 10 10% 80% 10% 0 2 0 1 0 0 R Y

11620 $ 356.73 $ 220.74 10 10% 80% 10% 0 2 0 1 0 0 R Y

11621 $ 422.51 $ 274.51 10 10% 80% 10% 0 2 0 1 0 0 R Y

11622 $ 470.58 $ 314.35 10 10% 80% 10% 0 2 0 1 0 0 R Y

11623 $ 549.64 $ 387.72 10 10% 80% 10% 0 2 0 1 0 0 R Y

11624 $ 619.22 $ 438.32 10 10% 80% 10% 0 2 0 1 0 0 R Y

11626 $ 741.92 $ 535.10 10 10% 80% 10% 0 2 0 1 0 0 R Y

11640 $ 368.75 $ 228.97 10 10% 80% 10% 0 2 0 1 0 0 R Y

11641 $ 437.06 $ 286.52 10 10% 80% 10% 0 2 0 1 0 0 R Y

11642 $ 497.78 $ 337.12 10 10% 80% 10% 0 2 0 1 0 0 R Y

11643 $ 584.43 $ 421.25 10 10% 80% 10% 0 2 0 1 0 0 R Y

11644 $ 719.15 $ 519.92 10 10% 80% 10% 0 2 0 1 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


11646 $ 935.47 $ 719.79 10 10% 80% 10% 0 2 0 1 0 0 R Y

11719 $ 25.93 $ 13.92 0 0% 0% 0% 0 2 0 1 0 0 R

11720 $ 59.46 $ 26.57 0 0% 0% 0% 0 0 0 1 0 0 R

11721 $ 82.23 $ 44.91 0 0% 0% 0% 0 0 0 1 0 0 R

11730 $ 192.91 $ 101.20 0 0% 0% 0% 0 2 0 1 0 0 R

11732 $ 58.19 $ 32.26 0 0% 0% 0% 0 0 0 1 0 0 R

11740 $ 91.71 $ 60.09 0 0% 0% 0% 0 2 0 1 0 0 R

11750 $ 282.10 $ 208.73 10 10% 80% 10% 0 2 0 1 0 0 R

11755 $ 245.41 $ 141.68 0 0% 0% 0% 0 2 0 0 0 0 R

11760 $ 347.88 $ 209.36 10 10% 80% 10% 0 2 0 1 0 0 R

11762 $ 512.33 $ 333.96 10 10% 80% 10% 0 2 0 1 0 0 R

11765 $ 310.56 $ 173.94 10 10% 80% 10% 0 2 0 1 0 0 R

11770 $ 504.10 $ 333.33 10 10% 80% 10% 0 2 0 1 0 0 R Y

11771 $ 1,038.57 $ 782.40 90 10% 71% 19% 0 2 0 1 0 0 R Y

11772 $ 1,258.04 $ 1,042.36 90 10% 71% 19% 0 2 0 1 0 0 R Y

11900 $ 102.47 $ 56.93 0 0% 0% 0% 0 2 0 1 0 0 R

11901 $ 127.77 $ 88.55 0 0% 0% 0% 0 2 0 1 0 0 R

11920 $ 311.19 $ 207.46 0 0% 0% 0% 0 2 0 0 0 0 R Y

11921 $ 361.16 $ 244.15 0 0% 0% 0% 0 2 0 0 0 0 R Y

11922 $ 112.59 $ 54.40 0 0% 0% 0% 0 0 0 0 0 0 R Y

11950 $ 141.68 $ 96.14 0 0% 0% 0% 0 2 0 0 0 0 R Y

11951 $ 181.53 $ 131.56 0 0% 0% 0% 0 2 0 0 0 0 R Y

11952 $ 225.17 $ 168.88 0 0% 0% 0% 0 2 0 0 0 0 R Y

11954 $ 287.16 $ 208.09 0 0% 0% 0% 0 2 0 0 0 0 R Y

11960 $ 1,738.74 $ 1,738.74 90 10% 71% 19% 0 2 0 1 0 0 R

11970 $ 1,112.57 $ 1,112.57 90 10% 71% 19% 0 2 1 1 0 0 R

11971 $ 865.89 $ 584.43 90 10% 71% 19% 0 2 1 0 0 0 R



11981 $ 257.43 $ 149.27 0 0% 0% 0% 0 2 0 0 0 0 R

11982 $ 290.95 $ 180.90 0 0% 0% 0% 0 2 0 0 0 0 R

11983 $ 407.96 $ 317.52 0 0% 0% 0% 0 2 0 0 0 0 R

12001 $ 164.45 $ 79.70 0 0% 0% 0% 0 2 0 1 0 0 R

12002 $ 198.61 $ 105.00 0 0% 0% 0% 0 2 0 1 0 0 R

12004 $ 232.76 $ 131.56 0 0% 0% 0% 0 2 0 1 0 0 R

12005 $ 292.85 $ 170.14 0 0% 0% 0% 0 2 0 1 0 0 R

12006 $ 345.35 $ 209.36 0 0% 0% 0% 0 2 0 1 0 0 R

12007 $ 395.31 $ 262.49 0 0% 0% 0% 0 2 0 1 1 0 R

12011 $ 199.87 $ 98.67 0 0% 0% 0% 0 2 0 1 0 0 R

12013 $ 208.09 $ 103.10 0 0% 0% 0% 0 2 0 1 0 0 R

12014 $ 242.25 $ 132.83 0 0% 0% 0% 0 2 0 1 0 0 R

12015 $ 293.48 $ 167.61 0 0% 0% 0% 0 2 0 1 0 0 R

12016 $ 369.38 $ 228.97 0 0% 0% 0% 0 2 0 1 0 0 R

12017 $ 278.30 $ 278.30 0 0% 0% 0% 0 2 0 0 0 0 R

12018 $ 314.99 $ 314.99 0 0% 0% 0% 0 2 0 2 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


12020 $ 513.59 $ 343.45 10 10% 80% 10% 0 2 0 1 0 0 R

12021 $ 294.75 $ 250.47 10 10% 80% 10% 0 2 0 1 0 0 R

12031 $ 436.43 $ 281.46 10 10% 80% 10% 0 2 0 1 0 0 R

12032 $ 557.87 $ 358.63 10 10% 80% 10% 0 2 0 1 0 0 R

12034 $ 571.15 $ 378.87 10 10% 80% 10% 0 2 0 1 0 0 R

12035 $ 697.02 $ 437.06 10 10% 80% 10% 0 2 0 1 0 0 R

12036 $ 767.86 $ 505.37 10 10% 80% 10% 0 2 0 1 0 0 R

12037 $ 876.01 $ 595.18 10 10% 80% 10% 0 2 0 0 1 0 R

12041 $ 435.79 $ 276.40 10 10% 80% 10% 0 2 0 1 0 0 R

12042 $ 529.40 $ 368.12 10 10% 80% 10% 0 2 0 1 0 0 R

12044 $ 659.07 $ 392.78 10 10% 80% 10% 0 2 0 1 0 0 R

12045 $ 733.70 $ 492.72 10 10% 80% 10% 0 2 0 1 0 0 R

12046 $ 865.26 $ 559.13 10 10% 80% 10% 0 2 0 0 0 0 R

12047 $ 1,006.31 $ 677.41 10 10% 80% 10% 0 2 0 2 1 0 R

12051 $ 473.11 $ 314.35 10 10% 80% 10% 0 2 0 1 0 0 R

12052 $ 538.26 $ 374.44 10 10% 80% 10% 0 2 0 1 0 0 R

12053 $ 633.13 $ 398.48 10 10% 80% 10% 0 2 0 1 0 0 R

12054 $ 659.07 $ 405.43 10 10% 80% 10% 0 2 0 1 0 0 R

12055 $ 853.88 $ 557.23 10 10% 80% 10% 0 2 0 1 0 0 R

12056 $ 896.89 $ 625.54 10 10% 80% 10% 0 2 0 0 0 0 R

12057 $ 983.54 $ 706.50 10 10% 80% 10% 0 2 0 2 1 0 R

13100 $ 614.16 $ 377.60 10 10% 80% 10% 0 2 0 1 0 0 R

13101 $ 727.38 $ 465.52 10 10% 80% 10% 0 2 0 1 0 0 R

13102 $ 221.38 $ 134.72 0 0% 0% 0% 0 0 0 1 0 0 R

13120 $ 641.99 $ 433.90 10 10% 80% 10% 0 2 0 1 0 0 R

13121 $ 783.67 $ 490.19 10 10% 80% 10% 0 2 0 1 0 0 R

13122 $ 242.88 $ 155.60 0 0% 0% 0% 0 0 0 1 0 0 R

13131 $ 706.50 $ 458.56 10 10% 80% 10% 0 2 0 1 0 0 R

13132 $ 872.22 $ 577.47 10 10% 80% 10% 0 2 0 1 0 0 R

13133 $ 325.11 $ 239.72 0 0% 0% 0% 0 0 0 1 0 0 R

13151 $ 772.28 $ 526.24 10 10% 80% 10% 0 2 0 1 0 0 R

13152 $ 926.61 $ 638.19 10 10% 80% 10% 0 2 0 1 0 0 R

13153 $ 352.94 $ 258.06 0 0% 0% 0% 0 0 0 1 0 0 R

13160 $ 1,454.75 $ 1,454.75 90 10% 71% 19% 0 2 0 1 0 0 R

14000 $ 1,136.60 $ 919.66 90 10% 71% 19% 0 2 0 1 0 0 R

14001 $ 1,462.97 $ 1,199.85 90 10% 71% 19% 0 2 0 1 0 0 R

14020 $ 1,273.86 $ 1,042.99 90 10% 71% 19% 0 2 0 1 0 0 R

14021 $ 1,590.74 $ 1,317.50 90 10% 71% 19% 0 2 0 1 0 0 R

14040 $ 1,391.50 $ 1,160.01 90 10% 71% 19% 0 2 0 1 0 0 R

14041 $ 1,724.20 $ 1,428.82 90 10% 71% 19% 0 2 0 1 0 0 R

14060 $ 1,417.43 $ 1,235.27 90 10% 71% 19% 0 2 0 1 0 0 R

14061 $ 1,855.76 $ 1,529.39 90 10% 71% 19% 0 2 0 1 0 0 R

14301 $ 1,963.91 $ 1,612.24 90 10% 71% 19% 0 2 0 2 0 0 R

14302 $ 401.01 $ 401.01 0 0% 0% 0% 0 0 0 2 0 0 R

14350 $ 1,256.15 $ 1,256.15 90 10% 71% 19% 0 2 0 0 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


15002 $ 633.77 $ 411.76 0 0% 0% 0% 0 0 0 0 0 0 R

15003 $ 137.89 $ 82.23 0 0% 0% 0% 0 0 0 0 0 0 R

15004 $ 731.80 $ 490.82 0 0% 0% 0% 0 0 0 0 0 0 R

15005 $ 225.80 $ 165.08 0 0% 0% 0% 0 0 0 0 0 0 R

15040 $ 466.79 $ 230.86 0 0% 0% 0% 0 0 0 1 0 0 R

15050 $ 1,026.55 $ 812.76 90 10% 71% 19% 0 2 0 1 0 0 R

15100 $ 1,558.48 $ 1,300.42 90 10% 71% 19% 0 2 0 1 0 0 R

15101 $ 339.65 $ 201.14 0 0% 0% 0% 0 0 0 1 0 0 R

15110 $ 1,440.20 $ 1,251.09 90 10% 71% 19% 0 2 0 1 0 0 R

15111 $ 206.20 $ 184.69 0 0% 0% 0% 0 0 0 1 0 0 R

15115 $ 1,457.28 $ 1,268.16 90 10% 71% 19% 0 2 0 1 0 0 R

15116 $ 295.38 $ 268.81 0 0% 0% 0% 0 0 0 1 1 0 R

15120 $ 1,547.10 $ 1,268.80 90 10% 71% 19% 0 2 0 1 0 0 R

15121 $ 381.40 $ 242.25 0 0% 0% 0% 0 0 0 1 1 0 R

15130 $ 1,212.50 $ 1,017.06 90 10% 71% 19% 0 2 0 1 0 0 R

15131 $ 161.29 $ 147.37 0 0% 0% 0% 0 0 0 1 1 0 R

15135 $ 1,529.39 $ 1,338.37 90 10% 71% 19% 0 2 0 1 0 0 R

15136 $ 156.86 $ 146.74 0 0% 0% 0% 0 0 0 1 1 0 R

15150 $ 1,227.05 $ 1,120.79 90 10% 71% 19% 0 2 0 1 0 0 R

15151 $ 215.05 $ 197.97 0 0% 0% 0% 0 0 0 1 0 0 R

15152 $ 261.22 $ 244.78 0 0% 0% 0% 0 0 0 1 0 0 R

15155 $ 1,303.58 $ 1,204.91 90 10% 71% 19% 0 2 0 1 0 0 R

15156 $ 292.22 $ 275.77 0 0% 0% 0% 0 0 0 1 1 0 R

15157 $ 332.06 $ 309.29 0 0% 0% 0% 0 0 0 1 1 0 R

15200 $ 1,516.10 $ 1,227.68 90 10% 71% 19% 0 2 0 1 0 0 R

15201 $ 268.18 $ 142.31 0 0% 0% 0% 0 0 0 1 0 0 R

15220 $ 1,410.48 $ 1,127.75 90 10% 71% 19% 0 2 0 1 0 0 R

15221 $ 250.47 $ 129.66 0 0% 0% 0% 0 0 0 1 0 0 R

15240 $ 1,705.85 $ 1,471.83 90 10% 71% 19% 0 2 0 1 0 0 R

15241 $ 337.76 $ 202.40 0 0% 0% 0% 0 0 0 1 0 0 R

15260 $ 1,851.96 $ 1,579.35 90 10% 71% 19% 0 2 0 1 0 0 R

15261 $ 394.05 $ 255.53 0 0% 0% 0% 0 0 0 1 0 0 R

15271 $ 256.16 $ 153.70 0 0% 0% 0% 0 2 0 1 0 0 R

15272 $ 49.34 $ 30.99 0 0% 0% 0% 0 0 0 1 0 0 R

15273 $ 544.58 $ 366.22 0 0% 0% 0% 0 2 0 1 0 0 R

15274 $ 129.66 $ 82.23 0 0% 0% 0% 0 0 0 1 0 0 R

15275 $ 272.61 $ 174.57 0 0% 0% 0% 0 2 0 1 0 0 R

15276 $ 63.25 $ 45.54 0 0% 0% 0% 0 0 0 1 0 0 R

15277 $ 593.92 $ 411.76 0 0% 0% 0% 0 2 0 1 1 0 R

15278 $ 154.96 $ 103.73 0 0% 0% 0% 0 0 0 1 1 0 R

15570 $ 1,664.74 $ 1,339.64 90 10% 71% 19% 0 2 0 1 0 0 R

15572 $ 1,623.00 $ 1,366.20 90 10% 71% 19% 0 2 0 1 0 0 R

15574 $ 1,662.84 $ 1,399.09 90 10% 71% 19% 0 2 0 1 0 0 R

15576 $ 1,473.09 $ 1,228.95 90 10% 71% 19% 0 2 0 1 0 0 R

15600 $ 595.82 $ 380.77 90 10% 71% 19% 0 2 0 0 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


15610 $ 657.80 $ 446.55 90 10% 71% 19% 0 2 0 0 0 0 R

15620 $ 803.28 $ 597.08 90 10% 71% 19% 0 2 0 1 0 0 R

15630 $ 843.76 $ 636.93 90 10% 71% 19% 0 2 0 1 0 0 R

15650 $ 927.25 $ 702.71 90 10% 71% 19% 0 2 0 0 0 0 R

15731 $ 2,047.40 $ 1,837.41 90 10% 71% 19% 0 2 0 0 0 0 R

15732 $ 2,341.52 $ 2,037.28 90 10% 71% 19% 0 2 0 1 1 0 R

15734 $ 2,716.59 $ 2,383.26 90 10% 71% 19% 0 2 0 2 1 0 R

15736 $ 2,392.75 $ 2,064.48 90 10% 71% 19% 0 2 0 1 1 0 R

15738 $ 2,532.53 $ 2,224.50 90 10% 71% 19% 0 2 0 2 1 0 R

15740 $ 1,859.55 $ 1,562.28 90 10% 71% 19% 0 2 0 1 0 0 R

15750 $ 1,670.43 $ 1,670.43 90 10% 71% 19% 0 2 0 2 0 0 R

15756 $ 4,209.29 $ 4,209.29 90 10% 71% 19% 0 2 0 2 2 0 R

15757 $ 4,152.36 $ 4,152.36 90 10% 71% 19% 0 2 0 2 2 0 R

15758 $ 4,165.01 $ 4,165.01 90 10% 71% 19% 0 2 0 2 2 0 R

15760 $ 1,559.11 $ 1,298.52 90 10% 71% 19% 0 2 0 1 0 0 R

15770 $ 1,220.09 $ 1,220.09 90 10% 71% 19% 0 2 0 2 1 0 R

15775 $ 547.11 $ 404.17 0 0% 0% 0% 0 2 0 0 0 0 R

15776 $ 892.46 $ 642.62 0 0% 0% 0% 0 2 0 0 0 0 R

15777 $ 389.62 $ 389.62 0 0% 0% 0% 0 0 1 1 0 0 R

15780 $ 1,581.88 $ 1,187.20 90 10% 71% 19% 0 2 0 0 0 0 R

15781 $ 1,018.33 $ 794.42 90 10% 71% 19% 0 2 0 1 0 0 R

15782 $ 1,176.45 $ 822.25 90 10% 71% 19% 0 2 0 0 0 0 R

15783 $ 877.28 $ 679.94 90 10% 71% 19% 0 2 0 0 0 0 R

15786 $ 452.24 $ 249.21 10 10% 80% 10% 0 2 0 1 0 0 R

15787 $ 91.71 $ 30.99 0 0% 0% 0% 0 0 0 1 0 0 R






15820 $ 1,065.13 $ 955.08 90 10% 71% 19% 0 2 1 0 0 0 R Y

15821 $ 1,111.94 $ 996.19 90 10% 71% 19% 0 2 1 0 0 0 R Y

15822 $ 817.82 $ 715.99 90 10% 71% 19% 0 2 1 1 0 0 R Y

15823 $ 1,115.10 $ 997.45 90 10% 71% 19% 0 2 1 1 0 0 R Y

15824 $ 1,442.99 $ 1,442.99 0 0% 0% 0% 0 2 1 0 0 0 F Y

15825 $ 1,240.72 $ 1,240.72 0 0% 0% 0% 0 2 1 0 0 0 F Y

15826 $ 1,173.29 $ 1,173.29 0 0% 0% 0% 0 2 1 0 0 0 F Y

15828 $ 4,018.82 $ 4,018.82 0 0% 0% 0% 0 2 1 0 0 0 F Y

15829 By Report By Report 0 0% 0% 0% 0 2 1 0 0 0 N Y

15830 $ 2,130.26 $ 2,130.26 90 10% 71% 19% 0 2 0 2 1 0 R Y

15832 $ 1,664.74 $ 1,664.74 90 10% 71% 19% 0 2 1 2 1 0 R Y

15833 $ 1,557.22 $ 1,557.22 90 10% 71% 19% 0 2 1 0 0 0 R Y

15834 $ 1,616.04 $ 1,616.04 90 10% 71% 19% 0 2 1 0 0 0 R Y

15835 $ 1,659.68 $ 1,659.68 90 10% 71% 19% 0 2 0 0 0 0 R Y

15836 $ 1,436.41 $ 1,436.41 90 10% 71% 19% 0 2 1 0 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


15837 $ 1,560.38 $ 1,299.16 90 10% 71% 19% 0 2 0 0 0 0 R Y

15838 $ 1,036.04 $ 1,036.04 90 10% 71% 19% 0 2 0 0 0 0 R Y

15839 $ 1,605.29 $ 1,340.27 90 10% 71% 19% 0 2 0 0 0 0 R Y

15840 $ 1,828.56 $ 1,828.56 90 10% 71% 19% 0 2 0 1 0 0 R

15841 $ 2,888.00 $ 2,888.00 90 10% 71% 19% 0 2 0 2 1 0 R

15842 $ 4,421.18 $ 4,421.18 90 10% 71% 19% 0 2 0 2 1 0 R

15845 $ 1,831.72 $ 1,831.72 90 10% 71% 19% 0 2 0 2 0 0 R


15850 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

15851 $ 182.16 $ 82.86 0 0% 0% 0% 0 2 0 1 0 0 R

15852 $ 84.12 $ 84.12 0 0% 0% 0% 0 2 0 1 0 0 R

15860 $ 197.97 $ 197.97 0 0% 0% 0% 0 2 0 0 0 0 R





15920 $ 1,123.32 $ 1,123.32 90 10% 71% 19% 0 2 0 0 0 0 R

15922 $ 1,425.66 $ 1,425.66 90 10% 71% 19% 0 2 0 2 1 0 R

15931 $ 1,236.54 $ 1,236.54 90 10% 71% 19% 0 2 0 1 0 0 R

15933 $ 1,528.12 $ 1,528.12 90 10% 71% 19% 0 2 0 0 0 0 R

15934 $ 1,681.82 $ 1,681.82 90 10% 71% 19% 0 2 0 1 0 0 R

15935 $ 1,997.44 $ 1,997.44 90 10% 71% 19% 0 2 0 2 1 0 R

15936 $ 1,607.82 $ 1,607.82 90 10% 71% 19% 0 2 0 1 1 0 R

15937 $ 1,865.24 $ 1,865.24 90 10% 71% 19% 0 2 0 1 1 0 R

15940 $ 1,261.84 $ 1,261.84 90 10% 71% 19% 0 2 0 1 0 0 R

15941 $ 1,628.69 $ 1,628.69 90 10% 71% 19% 0 2 0 0 0 0 R

15944 $ 1,613.51 $ 1,613.51 90 10% 71% 19% 0 2 0 0 0 0 R

15945 $ 1,782.39 $ 1,782.39 90 10% 71% 19% 0 2 0 0 0 0 R

15946 $ 2,962.63 $ 2,962.63 90 10% 71% 19% 0 2 0 1 1 0 R

15950 $ 1,070.19 $ 1,070.19 90 10% 71% 19% 0 2 0 1 0 0 R

15951 $ 1,585.05 $ 1,585.05 90 10% 71% 19% 0 2 0 0 1 0 R

15952 $ 1,636.28 $ 1,636.28 90 10% 71% 19% 0 2 0 2 1 0 R

15953 $ 1,812.75 $ 1,812.75 90 10% 71% 19% 0 2 0 1 1 0 R

15956 $ 2,078.40 $ 2,078.40 90 10% 71% 19% 0 2 0 1 1 0 R

15958 $ 2,124.57 $ 2,124.57 90 10% 71% 19% 0 2 0 1 1 0 R

15999 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N

16000 $ 125.87 $ 82.86 0 0% 0% 0% 0 2 0 1 0 0 R

16020 $ 150.54 $ 99.30 0 0% 0% 0% 0 2 0 1 0 0 R

16025 $ 268.81 $ 202.40 0 0% 0% 0% 0 2 0 1 0 0 R

16030 $ 337.76 $ 242.88 0 0% 0% 0% 0 2 0 1 0 0 R

16035 $ 351.04 $ 351.04 0 0% 0% 0% 0 2 0 1 0 0 R

16036 $ 146.11 $ 146.11 0 0% 0% 0% 0 0 0 1 0 0 R

17000 $ 122.71 $ 98.04 10 10% 80% 10% 0 2 0 1 0 0 R Y

17003 $ 10.12 $ 4.43 0 0% 0% 0% 0 0 0 1 0 0 R Y

17004 $ 275.77 $ 182.16 10 10% 80% 10% 0 0 0 1 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


17106 $ 627.44 $ 507.90 90 10% 71% 19% 0 2 0 1 0 0 R Y

17107 $ 791.26 $ 633.13 90 10% 71% 19% 0 2 0 1 0 0 R Y

17108 $ 1,173.92 $ 966.46 90 10% 71% 19% 0 2 0 0 0 0 R Y

17110 $ 205.56 $ 129.03 10 10% 80% 10% 0 2 0 1 0 0 R Y

17111 $ 242.88 $ 158.13 10 10% 80% 10% 0 2 0 1 0 0 R Y

17250 $ 146.11 $ 67.68 0 0% 0% 0% 0 2 0 1 0 0 R

17260 $ 173.31 $ 128.40 10 10% 80% 10% 0 2 0 1 0 0 R Y

17261 $ 263.12 $ 168.25 10 10% 80% 10% 0 2 0 1 0 0 R Y

17262 $ 320.68 $ 213.15 10 10% 80% 10% 0 2 0 1 0 0 R Y

17263 $ 349.77 $ 235.92 10 10% 80% 10% 0 2 0 1 0 0 R Y

17264 $ 373.81 $ 251.10 10 10% 80% 10% 0 2 0 1 0 0 R Y

17266 $ 425.04 $ 295.38 10 10% 80% 10% 0 2 0 1 0 0 R Y

17270 $ 276.40 $ 183.43 10 10% 80% 10% 0 2 0 1 0 0 R Y

17271 $ 299.17 $ 203.03 10 10% 80% 10% 0 2 0 1 0 0 R Y

17272 $ 340.92 $ 233.39 10 10% 80% 10% 0 2 0 1 0 0 R Y

17273 $ 380.13 $ 264.39 10 10% 80% 10% 0 2 0 1 0 0 R Y

17274 $ 449.08 $ 323.21 10 10% 80% 10% 0 2 0 1 0 0 R Y

17276 $ 517.39 $ 385.83 10 10% 80% 10% 0 2 0 1 0 0 R Y

17280 $ 259.33 $ 166.98 10 10% 80% 10% 0 2 0 1 0 0 R Y

17281 $ 325.74 $ 228.97 10 10% 80% 10% 0 2 0 1 0 0 R Y

17282 $ 373.81 $ 263.12 10 10% 80% 10% 0 2 0 1 0 0 R Y

17283 $ 446.55 $ 328.90 10 10% 80% 10% 0 2 0 1 0 0 R Y

17284 $ 509.80 $ 383.30 10 10% 80% 10% 0 2 0 1 0 0 R Y

17286 $ 650.21 $ 512.33 10 10% 80% 10% 0 2 0 1 0 0 R Y

17311 $ 1,213.77 $ 690.06 0 0% 0% 0% 0 2 0 1 0 0 R Y

17312 $ 715.36 $ 366.85 0 0% 0% 0% 0 0 0 1 0 0 R Y

17313 $ 1,135.97 $ 619.22 0 0% 0% 0% 0 2 0 1 0 0 R Y

17314 $ 686.90 $ 340.92 0 0% 0% 0% 0 0 0 1 0 0 R Y

17315 $ 146.74 $ 97.41 0 0% 0% 0% 0 0 0 1 0 0 R Y





19000 $ 208.09 $ 79.06 0 0% 0% 0% 0 2 0 1 0 0 R Y

19001 $ 48.70 $ 39.85 0 0% 0% 0% 0 0 0 1 0 0 R Y

19020 $ 865.89 $ 554.70 90 10% 71% 19% 0 2 1 1 0 0 R

19030 $ 304.87 $ 142.31 0 0% 0% 0% 0 2 1 1 0 0 R Y

19081 $ 1,291.57 $ 308.03 0 0% 0% 0% 0 2 1 0 0 0 R Y

19082 $ 1,071.46 $ 154.96 0 0% 0% 0% 0 0 0 0 0 0 R Y

19083 $ 1,252.98 $ 289.69 0 0% 0% 0% 0 2 1 0 0 0 R Y

19084 $ 1,030.34 $ 144.84 0 0% 0% 0% 0 0 0 0 0 0 R Y

19085 $ 1,910.15 $ 339.02 0 0% 0% 0% 0 2 1 0 0 0 R Y

19086 $ 1,534.45 $ 168.88 0 0% 0% 0% 0 0 0 0 0 0 R Y

19100 $ 275.14 $ 124.60 0 0% 0% 0% 0 2 1 1 0 0 R Y

19101 $ 620.48 $ 397.84 10 10% 80% 10% 0 2 1 1 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY



19110 $ 884.24 $ 618.59 90 10% 71% 19% 0 2 1 1 0 0 R Y

19112 $ 840.59 $ 566.72 90 10% 71% 19% 0 2 1 0 0 0 R Y

19120 $ 890.56 $ 743.19 90 10% 71% 19% 0 2 1 1 0 0 R Y

19125 $ 985.44 $ 823.52 90 10% 71% 19% 0 2 1 1 1 0 R Y

19126 $ 287.79 $ 287.79 0 0% 0% 0% 0 0 0 1 1 0 R Y

19260 $ 2,163.15 $ 2,163.15 90 10% 71% 19% 0 2 0 2 1 0 R Y

19271 $ 2,937.96 $ 2,937.96 90 10% 71% 19% 0 2 0 2 1 0 R Y

19272 $ 3,209.31 $ 3,209.31 90 10% 71% 19% 0 2 0 2 1 0 R Y

19281 $ 444.65 $ 185.32 0 0% 0% 0% 0 2 1 0 0 0 R Y

19282 $ 310.56 $ 92.98 0 0% 0% 0% 0 0 0 0 0 0 R Y

19283 $ 502.84 $ 186.59 0 0% 0% 0% 0 2 1 0 0 0 R Y

19284 $ 380.13 $ 93.61 0 0% 0% 0% 0 0 0 0 0 0 R Y

19285 $ 968.99 $ 158.76 0 0% 0% 0% 0 2 1 0 0 0 R Y

19286 $ 848.18 $ 79.70 0 0% 0% 0% 0 0 0 0 0 0 R Y

19287 $ 1,623.63 $ 237.19 0 0% 0% 0% 0 2 1 0 0 0 R Y

19288 $ 1,310.54 $ 118.28 0 0% 0% 0% 0 0 0 0 0 0 R Y












19316 $ 1,399.72 $ 1,399.72 90 10% 71% 19% 0 2 1 2 1 0 R Y

19318 $ 2,006.92 $ 2,006.92 90 10% 71% 19% 0 2 1 2 1 0 R Y

19324 $ 892.46 $ 892.46 90 10% 71% 19% 0 2 1 0 0 0 R Y

19325 $ 1,172.66 $ 1,172.66 90 10% 71% 19% 0 2 1 0 0 0 R Y

19328 $ 903.21 $ 903.21 90 10% 71% 19% 0 2 1 1 0 0 R Y

19330 $ 1,154.95 $ 1,154.95 90 10% 71% 19% 0 2 1 1 0 0 R Y

19340 $ 1,829.82 $ 1,829.82 90 10% 71% 19% 0 2 1 1 1 0 R Y

19342 $ 1,683.72 $ 1,683.72 90 10% 71% 19% 0 2 1 0 1 0 R Y

19350 $ 1,506.62 $ 1,228.95 90 10% 71% 19% 0 2 1 1 0 0 R Y


19357 $ 2,759.60 $ 2,759.60 90 10% 71% 19% 0 2 1 2 1 0 R Y

19361 $ 2,868.39 $ 2,868.39 90 10% 71% 19% 0 2 1 2 1 0 R Y

19364 $ 5,009.40 $ 5,009.40 90 10% 71% 19% 0 2 1 2 1 0 R Y

19366 $ 2,555.30 $ 2,555.30 90 10% 71% 19% 0 2 1 2 1 0 R Y

19367 $ 3,253.58 $ 3,253.58 90 10% 71% 19% 0 2 1 2 1 0 R Y

19368 $ 4,004.36 $ 4,004.36 90 10% 71% 19% 0 2 1 2 1 0 R Y

19369 $ 3,695.07 $ 3,695.07 90 10% 71% 19% 0 2 1 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


19370 $ 1,252.35 $ 1,252.35 90 10% 71% 19% 0 2 1 1 0 0 R Y

19371 $ 1,430.08 $ 1,430.08 90 10% 71% 19% 0 2 1 1 0 0 R Y

19380 $ 1,411.74 $ 1,411.74 90 10% 71% 19% 0 2 1 1 0 0 R Y

19396 $ 540.16 $ 266.28 0 0% 0% 0% 0 2 1 0 0 0 R Y


20005 $ 568.62 $ 426.31 10 10% 80% 10% 0 2 0 1 0 0 R

20100 $ 1,089.17 $ 1,089.17 10 10% 80% 10% 0 2 1 2 0 0 R

20101 $ 819.72 $ 373.81 10 10% 80% 10% 0 2 0 1 0 0 R

20102 $ 891.83 $ 457.30 10 10% 80% 10% 0 2 0 1 0 0 R

20103 $ 1,070.19 $ 631.87 10 10% 80% 10% 0 2 0 0 0 0 R

20150 $ 1,699.53 $ 1,699.53 90 10% 69% 21% 0 2 1 2 1 0 R Y

20200 $ 380.77 $ 171.41 0 0% 0% 0% 0 2 0 1 0 0 R

20205 $ 528.14 $ 279.57 0 0% 0% 0% 0 2 0 1 0 0 R

20206 $ 440.22 $ 108.79 0 0% 0% 0% 0 2 0 1 0 0 R

20220 $ 311.82 $ 132.19 0 0% 0% 0% 0 2 0 1 0 0 R

20225 $ 977.85 $ 198.61 0 0% 0% 0% 0 2 0 1 0 0 R

20240 $ 278.30 $ 278.30 10 10% 80% 10% 0 2 0 1 0 0 R

20245 $ 640.72 $ 640.72 10 10% 80% 10% 0 2 0 1 0 0 R

20250 $ 700.18 $ 700.18 10 10% 80% 10% 0 2 0 1 0 0 R

20251 $ 765.96 $ 765.96 10 10% 80% 10% 0 2 0 2 0 0 R

20500 $ 189.12 $ 153.70 10 10% 80% 10% 0 2 0 1 0 0 R

20501 $ 219.48 $ 69.58 0 0% 0% 0% 0 2 0 1 0 0 R

20520 $ 375.07 $ 268.18 10 10% 80% 10% 0 2 0 1 0 0 R

20525 $ 882.34 $ 449.71 10 10% 80% 10% 0 2 0 1 0 0 R

20526 $ 140.42 $ 104.36 0 0% 0% 0% 0 2 1 1 0 0 R

20527 $ 153.07 $ 120.81 0 0% 0% 0% 0 2 1 1 0 0 R

20550 $ 95.51 $ 70.84 0 0% 0% 0% 0 2 1 1 0 0 R

20551 $ 110.69 $ 77.17 0 0% 0% 0% 0 2 0 1 0 0 R

20552 $ 101.20 $ 68.94 0 0% 0% 0% 0 2 0 1 0 0 R Y

20553 $ 116.38 $ 78.43 0 0% 0% 0% 0 2 0 1 0 0 R Y


20600 $ 87.29 $ 64.52 0 0% 0% 0% 0 2 1 1 0 0 R

20604 $ 132.19 $ 84.76 0 0% 0% 0% 0 2 1 1 0 0 R

20605 $ 91.71 $ 67.68 0 0% 0% 0% 0 2 1 1 0 0 R

20606 $ 146.11 $ 95.51 0 0% 0% 0% 0 2 1 1 0 0 R

20610 $ 109.42 $ 83.49 0 0% 0% 0% 0 2 1 1 0 0 R

20611 $ 165.72 $ 111.32 0 0% 0% 0% 0 2 1 1 0 0 R

20612 $ 110.69 $ 75.90 0 0% 0% 0% 0 2 0 1 0 0 R

20615 $ 444.02 $ 296.01 10 10% 80% 10% 0 2 0 1 0 0 R

20650 $ 382.66 $ 288.42 10 10% 80% 10% 0 2 0 1 1 0 R

20660 $ 435.16 $ 435.16 0 0% 0% 0% 0 2 0 1 0 0 R

20661 $ 912.70 $ 912.70 90 10% 69% 21% 0 2 0 1 0 0 R

20662 $ 803.28 $ 803.28 90 10% 69% 21% 0 2 0 0 0 0 R

20663 $ 827.94 $ 827.94 90 10% 69% 21% 0 2 1 0 0 0 R

20664 $ 1,566.07 $ 1,566.07 90 10% 69% 21% 0 2 0 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


20665 $ 194.81 $ 166.98 10 10% 80% 10% 0 2 0 0 0 0 R

20670 $ 707.14 $ 270.08 10 10% 80% 10% 0 2 0 1 0 0 R

20680 $ 1,134.71 $ 770.39 90 10% 69% 21% 0 2 0 0 0 0 R

20690 $ 1,077.15 $ 1,077.15 90 10% 69% 21% 0 2 0 1 0 0 R

20692 $ 2,034.75 $ 2,034.75 90 10% 69% 21% 0 2 0 2 1 0 R

20693 $ 810.23 $ 810.23 90 10% 69% 21% 0 2 0 1 0 0 R

20694 $ 777.98 $ 616.69 90 10% 69% 21% 0 2 0 1 0 0 R

20696 $ 2,190.98 $ 2,190.98 90 10% 69% 21% 0 2 0 2 1 0 R

20697 $ 3,980.96 $ 3,980.96 0 0% 0% 0% 3 0 0 2 1 0 R

20802 $ 5,016.99 $ 5,016.99 90 10% 69% 21% 0 2 1 2 1 0 R

20805 $ 5,647.59 $ 5,647.59 90 10% 69% 21% 0 2 1 2 1 0 R

20808 $ 7,278.81 $ 7,278.81 90 10% 69% 21% 0 2 1 2 1 0 R

20816 $ 3,835.48 $ 3,835.48 90 10% 69% 21% 0 2 0 2 1 0 R

20822 $ 3,259.91 $ 3,259.91 90 10% 69% 21% 0 2 0 2 1 0 R

20824 $ 3,550.86 $ 3,550.86 90 10% 69% 21% 0 2 1 2 1 0 R

20827 $ 3,352.88 $ 3,352.88 90 10% 69% 21% 0 2 1 2 1 0 R

20838 $ 4,920.85 $ 4,920.85 90 10% 69% 21% 0 2 1 2 1 0 R

20900 $ 769.75 $ 342.82 0 0% 0% 0% 0 2 0 2 1 0 R

20902 $ 516.12 $ 516.12 0 0% 0% 0% 0 2 0 2 1 0 R

20910 $ 827.94 $ 827.94 90 10% 69% 21% 0 2 0 0 0 0 R

20912 $ 870.95 $ 870.95 90 10% 69% 21% 0 2 0 0 0 0 R

20920 $ 719.79 $ 719.79 90 10% 69% 21% 0 2 0 1 1 0 R

20922 $ 1,072.09 $ 883.60 90 10% 69% 21% 0 2 0 2 1 0 R

20924 $ 924.08 $ 924.08 90 10% 69% 21% 0 2 0 2 1 0 R

20926 $ 771.02 $ 771.02 90 10% 69% 21% 0 2 0 1 0 0 R


20931 $ 200.50 $ 200.50 0 0% 0% 0% 0 0 0 1 1 0 R


20937 $ 301.70 $ 301.70 0 0% 0% 0% 0 0 0 2 1 0 R

20938 $ 331.43 $ 331.43 0 0% 0% 0% 0 0 0 2 1 0 R

20950 $ 468.05 $ 165.72 0 0% 0% 0% 0 2 0 0 0 0 R

20955 $ 4,553.37 $ 4,553.37 90 10% 69% 21% 0 2 0 2 1 0 R

20956 $ 4,801.31 $ 4,801.31 90 10% 69% 21% 0 2 0 2 1 0 R

20957 $ 4,146.67 $ 4,146.67 90 10% 69% 21% 0 2 0 2 1 0 R

20962 $ 3,934.15 $ 3,934.15 90 10% 69% 21% 0 2 0 2 1 0 R

20969 $ 5,018.26 $ 5,018.26 90 10% 69% 21% 0 2 0 2 1 0 R

20970 $ 5,206.74 $ 5,206.74 90 10% 69% 21% 0 2 0 2 1 0 R

20972 $ 4,395.24 $ 4,395.24 90 10% 69% 21% 0 2 0 2 0 0 R

20973 $ 4,510.99 $ 4,510.99 90 10% 69% 21% 0 2 1 2 1 0 R

20974 $ 141.68 $ 92.35 0 0% 0% 0% 0 0 0 1 0 0 R Y

20975 $ 321.31 $ 321.31 0 0% 0% 0% 0 0 0 2 1 0 R Y

20979 $ 94.88 $ 58.19 0 0% 0% 0% 0 0 0 1 0 0 R Y



20985 $ 265.65 $ 265.65 0 0% 0% 0% 0 0 0 0 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY



21010 $ 1,380.12 $ 1,380.12 90 10% 69% 21% 0 2 1 0 0 0 R Y

21011 $ 640.72 $ 475.64 90 10% 69% 21% 0 2 0 2 0 0 R Y

21012 $ 616.69 $ 616.69 90 10% 69% 21% 0 2 0 2 0 0 R Y

21013 $ 950.65 $ 731.80 90 10% 69% 21% 0 2 0 2 0 0 R Y

21014 $ 949.38 $ 949.38 90 10% 69% 21% 0 2 0 2 0 0 R Y

21015 $ 1,287.77 $ 1,287.77 90 10% 69% 21% 0 2 0 1 0 0 R Y


21025 $ 1,644.50 $ 1,383.91 90 10% 69% 21% 0 2 0 1 0 0 R

21026 $ 1,149.25 $ 925.98 90 10% 69% 21% 0 2 0 1 0 0 R

21029 $ 1,419.96 $ 1,175.82 90 10% 69% 21% 0 2 0 0 0 0 R Y

21030 $ 964.56 $ 773.55 90 10% 69% 21% 0 2 1 1 0 0 R Y

21031 $ 737.50 $ 549.01 90 10% 69% 21% 0 2 1 1 0 0 R Y

21032 $ 746.35 $ 540.79 90 10% 69% 21% 0 2 0 1 0 0 R Y

21034 $ 2,412.99 $ 2,118.88 90 10% 69% 21% 0 2 0 2 1 0 R Y

21040 $ 970.89 $ 774.18 90 10% 69% 21% 0 2 0 1 0 0 R Y

21044 $ 1,601.49 $ 1,601.49 90 10% 69% 21% 0 2 0 2 1 0 R Y

21045 $ 2,239.05 $ 2,239.05 90 10% 69% 21% 0 2 0 2 1 0 R Y

21046 $ 2,062.58 $ 2,062.58 90 10% 69% 21% 0 2 0 0 1 0 R Y

21047 $ 2,406.03 $ 2,406.03 90 10% 69% 21% 0 2 0 2 1 0 R Y

21048 $ 2,115.08 $ 2,115.08 90 10% 69% 21% 0 2 0 0 1 0 R Y

21049 $ 2,199.84 $ 2,199.84 90 10% 69% 21% 0 2 0 2 1 0 R Y

21050 $ 1,528.12 $ 1,528.12 90 10% 69% 21% 0 2 1 0 0 0 R Y

21060 $ 1,471.20 $ 1,471.20 90 10% 69% 21% 0 2 1 2 1 0 R Y

21070 $ 1,115.10 $ 1,115.10 90 10% 69% 21% 0 2 1 0 0 0 R Y

21073 $ 740.03 $ 470.58 90 10% 69% 21% 0 2 1 0 0 0 R Y

21076 $ 1,823.50 $ 1,516.74 10 10% 80% 10% 0 2 0 0 0 0 R

21077 $ 4,605.23 $ 3,844.34 90 10% 69% 21% 0 2 1 0 0 0 R

21079 $ 3,103.05 $ 2,559.73 90 10% 69% 21% 0 2 0 1 0 0 R

21080 $ 3,486.34 $ 2,850.68 90 10% 69% 21% 0 2 0 1 0 0 R

21081 $ 3,216.26 $ 2,622.35 90 10% 69% 21% 0 2 0 0 0 0 R

21082 $ 3,037.27 $ 2,447.78 90 10% 69% 21% 0 2 0 0 0 0 R

21083 $ 2,902.54 $ 2,279.53 90 10% 69% 21% 0 2 0 0 0 0 R

21084 $ 3,324.42 $ 2,640.06 90 10% 69% 21% 0 2 0 0 0 0 R

21085 $ 1,397.83 $ 1,035.40 10 10% 80% 10% 0 2 0 0 0 0 R

21086 $ 3,419.93 $ 2,843.09 90 10% 69% 21% 0 2 1 0 0 0 R

21087 $ 3,402.22 $ 2,822.22 90 10% 69% 21% 0 2 0 0 0 0 R



21100 $ 1,564.81 $ 750.78 90 10% 69% 21% 0 2 0 0 0 0 R

21110 $ 1,502.82 $ 1,255.51 90 10% 69% 21% 0 2 0 1 0 0 R

21116 $ 274.51 $ 80.33 0 0% 0% 0% 0 2 1 1 0 0 R

21120 $ 1,113.83 $ 882.34 90 10% 69% 21% 0 2 0 1 1 0 R Y

21121 $ 1,493.97 $ 1,244.13 90 10% 69% 21% 0 2 0 2 0 0 R Y

21122 $ 1,214.40 $ 1,214.40 90 10% 69% 21% 0 2 0 2 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


21123 $ 1,661.58 $ 1,661.58 90 10% 69% 21% 0 2 0 2 1 0 R Y

21125 $ 6,033.42 $ 1,347.86 90 10% 69% 21% 0 2 0 2 0 0 R Y

21127 $ 8,265.51 $ 1,633.12 90 10% 69% 21% 0 2 0 2 1 0 R Y

21137 $ 1,268.16 $ 1,268.16 90 10% 69% 21% 0 2 0 2 0 0 R Y

21138 $ 1,679.29 $ 1,679.29 90 10% 69% 21% 0 2 0 2 1 0 R Y

21139 $ 1,983.52 $ 1,983.52 90 10% 69% 21% 0 2 0 2 1 0 R Y

21141 $ 2,483.83 $ 2,483.83 90 10% 69% 21% 0 2 0 2 1 0 R Y

21142 $ 2,636.26 $ 2,636.26 90 10% 69% 21% 0 2 0 2 1 0 R Y

21143 $ 2,679.27 $ 2,679.27 90 10% 69% 21% 0 2 0 2 1 0 R Y

21145 $ 2,922.78 $ 2,922.78 90 10% 69% 21% 0 2 0 2 0 0 R Y

21146 $ 3,043.59 $ 3,043.59 90 10% 69% 21% 0 2 0 2 1 0 R Y

21147 $ 3,064.46 $ 3,064.46 90 10% 69% 21% 0 2 0 2 0 0 R Y

21150 $ 3,168.83 $ 3,168.83 90 10% 69% 21% 0 2 0 2 0 0 R Y

21151 $ 3,684.31 $ 3,684.31 90 10% 69% 21% 0 2 0 2 0 0 R Y

21154 $ 3,435.74 $ 3,435.74 90 10% 69% 21% 0 2 0 2 1 0 R Y

21155 $ 3,810.18 $ 3,810.18 90 10% 69% 21% 0 2 0 2 0 0 R Y

21159 $ 4,782.97 $ 4,782.97 90 10% 69% 21% 0 2 0 2 1 0 R Y

21160 $ 4,950.58 $ 4,950.58 90 10% 69% 21% 0 2 0 2 0 0 R Y

21172 $ 3,639.41 $ 3,639.41 90 10% 69% 21% 0 2 0 2 1 0 R Y

21175 $ 3,874.70 $ 3,874.70 90 10% 69% 21% 0 2 0 2 0 0 R Y

21179 $ 2,477.50 $ 2,477.50 90 10% 69% 21% 0 2 0 2 0 0 R Y

21180 $ 2,857.00 $ 2,857.00 90 10% 69% 21% 0 2 0 2 1 0 R Y

21181 $ 1,352.29 $ 1,352.29 90 10% 69% 21% 0 2 0 0 0 0 R Y

21182 $ 3,581.22 $ 3,581.22 90 10% 69% 21% 0 2 0 2 1 0 R Y

21183 $ 4,125.17 $ 4,125.17 90 10% 69% 21% 0 2 0 2 1 0 R Y

21184 $ 4,774.11 $ 4,774.11 90 10% 69% 21% 0 2 0 2 0 0 R Y

21188 $ 2,987.30 $ 2,987.30 90 10% 69% 21% 0 2 0 2 0 0 R Y

21193 $ 2,153.66 $ 2,153.66 90 10% 69% 21% 0 2 2 2 1 0 R Y

21194 $ 2,701.41 $ 2,701.41 90 10% 69% 21% 0 2 2 2 0 0 R Y

21195 $ 2,418.68 $ 2,418.68 90 10% 69% 21% 0 2 2 2 0 0 R Y

21196 $ 2,726.71 $ 2,726.71 90 10% 69% 21% 0 2 2 2 1 0 R Y

21198 $ 2,149.87 $ 2,149.87 90 10% 69% 21% 0 2 0 2 1 0 R Y

21199 $ 1,840.58 $ 1,840.58 90 10% 69% 21% 0 2 0 2 1 0 R Y

21206 $ 2,242.85 $ 2,242.85 90 10% 69% 21% 0 2 0 2 1 0 R Y

21208 $ 3,451.55 $ 1,545.83 90 10% 69% 21% 0 2 0 0 0 0 R

21209 $ 1,509.15 $ 1,141.03 90 10% 69% 21% 0 2 0 2 0 0 R

21210 $ 4,267.48 $ 1,594.53 90 10% 69% 21% 0 2 0 1 0 0 R

21215 $ 7,577.35 $ 1,659.05 90 10% 69% 21% 0 2 0 1 1 0 R

21230 $ 1,359.24 $ 1,359.24 90 10% 69% 21% 0 2 0 0 0 0 R

21235 $ 1,335.84 $ 1,039.20 90 10% 69% 21% 0 2 0 1 0 0 R

21240 $ 2,054.36 $ 2,054.36 90 10% 69% 21% 0 2 1 2 1 0 R Y

21242 $ 1,891.18 $ 1,891.18 90 10% 69% 21% 0 2 1 2 1 0 R Y

21243 $ 3,135.94 $ 3,135.94 90 10% 69% 21% 0 2 1 2 1 0 R Y

21244 $ 1,958.85 $ 1,958.85 90 10% 69% 21% 0 2 0 2 1 0 R

21245 $ 2,027.80 $ 1,612.88 90 10% 69% 21% 0 2 0 2 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


21246 $ 1,609.08 $ 1,609.08 90 10% 69% 21% 0 2 0 2 0 0 R Y

21247 $ 2,797.55 $ 2,797.55 90 10% 69% 21% 0 2 1 2 1 0 R

21248 $ 2,050.57 $ 1,666.64 90 10% 69% 21% 0 2 0 1 0 0 R

21249 $ 2,784.90 $ 2,350.37 90 10% 69% 21% 0 2 0 0 0 0 R

21255 $ 2,544.55 $ 2,544.55 90 10% 69% 21% 0 2 1 2 1 0 R

21256 $ 2,221.34 $ 2,221.34 90 10% 69% 21% 0 2 1 2 1 0 R






21270 $ 1,800.10 $ 1,342.17 90 10% 69% 21% 0 2 1 2 1 0 R

21275 $ 1,530.65 $ 1,530.65 90 10% 69% 21% 0 2 0 2 1 0 R

21280 $ 1,048.05 $ 1,048.05 90 10% 69% 21% 0 2 1 0 0 0 R

21282 $ 700.81 $ 700.81 90 10% 69% 21% 0 2 1 1 0 0 R




21310 $ 247.94 $ 48.70 0 0% 0% 0% 0 2 0 1 0 0 R

21315 $ 512.33 $ 277.67 10 10% 80% 10% 0 2 0 1 0 0 R

21320 $ 474.38 $ 246.04 10 10% 80% 10% 0 2 0 1 0 0 R

21325 $ 877.28 $ 877.28 90 10% 69% 21% 0 2 0 0 0 0 R

21330 $ 1,056.28 $ 1,056.28 90 10% 69% 21% 0 2 0 0 0 0 R

21335 $ 1,326.35 $ 1,326.35 90 10% 69% 21% 0 2 0 1 0 0 R

21336 $ 1,190.37 $ 1,190.37 90 10% 69% 21% 0 2 0 0 0 0 R

21337 $ 747.62 $ 542.69 90 10% 69% 21% 0 2 0 0 0 0 R

21338 $ 1,394.03 $ 1,394.03 90 10% 69% 21% 0 2 0 0 0 0 R

21339 $ 1,564.81 $ 1,564.81 90 10% 69% 21% 0 2 0 2 1 0 R

21340 $ 1,482.58 $ 1,482.58 90 10% 69% 21% 0 2 0 0 0 0 R

21343 $ 2,234.62 $ 2,234.62 90 10% 69% 21% 0 2 0 2 1 0 R

21344 $ 2,533.16 $ 2,533.16 90 10% 69% 21% 0 2 0 2 2 0 R

21345 $ 1,481.32 $ 1,182.78 90 10% 69% 21% 0 2 0 0 0 0 R

21346 $ 1,663.48 $ 1,663.48 90 10% 69% 21% 0 2 0 1 1 0 R

21347 $ 2,092.94 $ 2,092.94 90 10% 69% 21% 0 2 0 2 1 0 R

21348 $ 2,195.41 $ 2,195.41 90 10% 69% 21% 0 2 0 2 2 0 R

21355 $ 830.47 $ 611.63 10 10% 80% 10% 0 2 1 0 0 0 R

21356 $ 926.61 $ 693.22 10 10% 80% 10% 0 2 1 0 0 0 R

21360 $ 989.23 $ 989.23 90 10% 69% 21% 0 2 1 2 0 0 R

21365 $ 2,028.43 $ 2,028.43 90 10% 69% 21% 0 2 1 2 1 0 R

21366 $ 2,055.63 $ 2,055.63 90 10% 69% 21% 0 2 1 2 2 0 R

21385 $ 1,239.07 $ 1,239.07 90 10% 69% 21% 0 2 1 2 1 0 R

21386 $ 1,268.16 $ 1,268.16 90 10% 69% 21% 0 2 1 2 0 0 R

21387 $ 1,294.73 $ 1,294.73 90 10% 69% 21% 0 2 1 2 0 0 R

21390 $ 1,457.28 $ 1,457.28 90 10% 69% 21% 0 2 1 2 1 0 R

21395 $ 1,839.31 $ 1,839.31 90 10% 69% 21% 0 2 1 2 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


21400 $ 356.73 $ 289.05 90 10% 69% 21% 0 2 1 0 0 0 R

21401 $ 903.21 $ 559.13 90 10% 69% 21% 0 2 1 2 0 0 R

21406 $ 1,044.89 $ 1,044.89 90 10% 69% 21% 0 2 1 2 1 0 R

21407 $ 1,184.04 $ 1,184.04 90 10% 69% 21% 0 2 1 2 1 0 R

21408 $ 1,632.48 $ 1,632.48 90 10% 69% 21% 0 2 1 2 2 0 R

21421 $ 1,578.72 $ 1,300.42 90 10% 69% 21% 0 2 0 0 0 0 R

21422 $ 1,242.86 $ 1,242.86 90 10% 69% 21% 0 2 0 2 1 0 R

21423 $ 1,445.90 $ 1,445.90 90 10% 69% 21% 0 2 0 2 2 0 R

21431 $ 1,360.51 $ 1,360.51 90 10% 69% 21% 0 2 0 2 0 0 R

21432 $ 1,246.66 $ 1,246.66 90 10% 69% 21% 0 2 0 2 0 0 R

21433 $ 3,165.03 $ 3,165.03 90 10% 69% 21% 0 2 0 2 1 0 R

21435 $ 2,306.10 $ 2,306.10 90 10% 69% 21% 0 2 0 2 0 0 R

21436 $ 3,454.08 $ 3,454.08 90 10% 69% 21% 0 2 0 2 2 0 R

21440 $ 1,085.37 $ 878.54 90 10% 69% 21% 0 2 0 0 0 0 R

21445 $ 1,430.72 $ 1,159.37 90 10% 69% 21% 0 2 0 2 0 0 R

21450 $ 1,159.37 $ 925.35 90 10% 69% 21% 0 2 0 0 0 0 R

21451 $ 1,537.61 $ 1,261.84 90 10% 69% 21% 0 2 0 0 0 0 R

21452 $ 1,076.52 $ 630.60 90 10% 69% 21% 0 2 0 0 0 0 R

21453 $ 1,705.22 $ 1,456.65 90 10% 69% 21% 0 2 0 0 0 0 R

21454 $ 1,059.44 $ 1,059.44 90 10% 69% 21% 0 2 0 0 1 0 R

21461 $ 4,027.76 $ 1,745.70 90 10% 69% 21% 0 2 0 1 1 0 R

21462 $ 4,274.44 $ 1,942.41 90 10% 69% 21% 0 2 0 2 1 0 R

21465 $ 1,720.40 $ 1,720.40 90 10% 69% 21% 0 2 1 2 1 0 R

21470 $ 2,206.79 $ 2,206.79 90 10% 69% 21% 0 2 0 2 1 0 R

21480 $ 183.43 $ 57.56 0 0% 0% 0% 0 2 1 1 0 0 R

21485 $ 1,306.75 $ 1,089.80 90 10% 69% 21% 0 2 1 0 0 0 R

21490 $ 1,678.66 $ 1,678.66 90 10% 69% 21% 0 2 1 2 1 0 R

21497 $ 1,388.34 $ 1,149.89 90 10% 69% 21% 0 2 0 0 0 0 R


21501 $ 831.74 $ 585.06 90 10% 69% 21% 0 2 0 1 0 0 R

21502 $ 913.96 $ 913.96 90 10% 69% 21% 0 2 0 2 0 0 R

21510 $ 807.07 $ 807.07 90 10% 69% 21% 0 2 0 0 0 0 R

21550 $ 485.76 $ 289.05 10 10% 80% 10% 0 2 0 1 0 0 R

21552 $ 805.17 $ 805.17 90 10% 69% 21% 0 2 0 2 0 0 R Y

21554 $ 1,319.40 $ 1,319.40 90 10% 69% 21% 0 2 0 2 0 0 R Y

21555 $ 760.27 $ 557.23 90 10% 69% 21% 0 2 0 1 0 0 R Y

21556 $ 959.50 $ 959.50 90 10% 69% 21% 0 2 0 1 0 0 R Y

21557 $ 1,733.68 $ 1,733.68 90 10% 69% 21% 0 2 0 2 1 0 R Y


21600 $ 1,009.47 $ 1,009.47 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

21610 $ 2,098.00 $ 2,098.00 90 10% 69% 21% 0 2 0 2 0 0 R Y

21615 $ 1,115.10 $ 1,115.10 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

21616 $ 1,346.59 $ 1,346.59 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

21620 $ 910.80 $ 910.80 90 10% 69% 21% 0 2 0 2 1 0 R

21627 $ 978.48 $ 978.48 90 10% 69% 21% 0 2 0 2 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


21630 $ 2,190.98 $ 2,190.98 90 10% 69% 21% 0 2 0 2 1 0 R Y

21632 $ 2,148.60 $ 2,148.60 90 10% 69% 21% 0 2 0 2 1 0 R Y


21700 $ 660.96 $ 660.96 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

21705 $ 980.38 $ 980.38 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

21720 $ 888.03 $ 888.03 90 10% 69% 21% 0 2 0 2 0 0 R Y

21725 $ 981.01 $ 981.01 90 10% 69% 21% 0 2 0 2 1 0 R Y

21740 $ 1,835.52 $ 1,835.52 90 10% 69% 21% 0 2 0 2 1 0 R Y



21750 $ 1,223.89 $ 1,223.89 90 10% 69% 21% 0 2 0 2 1 0 R

21811 $ 1,087.90 $ 1,087.90 0 0% 0% 0% 0 2 1 2 0 0 R

21812 $ 1,302.95 $ 1,302.95 0 0% 0% 0% 0 2 1 2 0 0 R

21813 $ 1,719.77 $ 1,719.77 0 0% 0% 0% 0 2 1 2 0 0 R

21820 $ 257.43 $ 263.75 90 10% 69% 21% 0 2 0 1 0 0 R

21825 $ 974.05 $ 974.05 90 10% 69% 21% 0 2 0 2 1 0 R

21899 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N Y-UR

21920 $ 475.64 $ 294.11 10 10% 80% 10% 0 2 0 1 0 0 R

21925 $ 820.99 $ 648.95 90 10% 69% 21% 0 2 0 1 0 0 R

21930 $ 863.36 $ 662.86 90 10% 69% 21% 0 2 0 1 0 0 R

21931 $ 847.55 $ 847.55 90 10% 69% 21% 0 2 0 2 0 0 R Y

21932 $ 1,193.53 $ 1,193.53 90 10% 69% 21% 0 2 0 2 0 0 R

21933 $ 1,330.15 $ 1,330.15 90 10% 69% 21% 0 2 0 2 0 0 R

21935 $ 1,857.65 $ 1,857.65 90 10% 69% 21% 0 2 0 1 1 0 R Y


22010 $ 1,718.50 $ 1,718.50 90 10% 69% 21% 0 2 0 0 0 0 R

22015 $ 1,693.84 $ 1,693.84 90 10% 69% 21% 0 2 0 1 0 0 R

22100 $ 1,644.50 $ 1,644.50 90 10% 69% 21% 0 2 0 2 1 0 R Y

22101 $ 1,538.24 $ 1,538.24 90 10% 69% 21% 0 2 0 2 1 0 R Y

22102 $ 1,419.96 $ 1,419.96 90 10% 69% 21% 0 2 0 2 1 0 R Y

22103 $ 251.74 $ 251.74 0 0% 0% 0% 0 0 0 2 1 0 R Y

22110 $ 1,878.53 $ 1,878.53 90 10% 69% 21% 0 2 0 2 1 0 R Y

22112 $ 1,965.18 $ 1,965.18 90 10% 69% 21% 0 2 0 2 1 0 R Y

22114 $ 1,795.04 $ 1,795.04 90 10% 69% 21% 0 2 0 2 1 0 R Y

22116 $ 252.37 $ 252.37 0 0% 0% 0% 0 0 0 2 1 0 R Y

22206 $ 4,395.24 $ 4,395.24 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

22207 $ 4,319.34 $ 4,319.34 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

22208 $ 1,046.16 $ 1,046.16 0 0% 0% 0% 0 0 0 2 1 0 R Y-UR

22210 $ 3,212.47 $ 3,212.47 90 10% 69% 21% 0 2 0 2 1 0 R Y

22212 $ 2,683.07 $ 2,683.07 90 10% 69% 21% 0 2 0 2 1 0 R Y

22214 $ 2,690.02 $ 2,690.02 90 10% 69% 21% 0 2 0 2 1 0 R Y

22216 $ 653.37 $ 653.37 0 0% 0% 0% 0 0 0 2 1 0 R Y

22220 $ 2,881.67 $ 2,881.67 90 10% 69% 21% 0 2 0 2 1 0 R Y

22222 $ 2,730.50 $ 2,730.50 90 10% 69% 21% 0 2 0 2 1 0 R Y

22224 $ 2,863.33 $ 2,863.33 90 10% 69% 21% 0 2 0 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


22226 $ 650.84 $ 650.84 0 0% 0% 0% 0 0 0 2 1 0 R Y

22310 $ 558.50 $ 512.33 90 10% 69% 21% 0 2 0 1 0 0 R Y

22315 $ 1,605.92 $ 1,396.56 90 10% 69% 21% 0 2 0 1 0 0 R Y

22318 $ 2,925.95 $ 2,925.95 90 10% 69% 21% 0 2 0 2 2 0 R Y

22319 $ 3,249.79 $ 3,249.79 90 10% 69% 21% 0 2 0 2 2 0 R Y

22325 $ 2,590.09 $ 2,590.09 90 10% 69% 21% 0 2 0 2 1 0 R Y

22326 $ 2,672.31 $ 2,672.31 90 10% 69% 21% 0 2 0 2 1 0 R Y

22327 $ 2,698.25 $ 2,698.25 90 10% 69% 21% 0 2 0 2 1 0 R Y

22328 $ 504.74 $ 504.74 0 0% 0% 0% 0 0 0 2 1 0 R Y

22505 $ 240.35 $ 240.35 10 10% 80% 10% 0 2 0 1 0 0 R Y









22532 $ 3,192.23 $ 3,192.23 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22533 $ 3,000.58 $ 3,000.58 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22534 $ 648.31 $ 648.31 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22548 $ 3,471.79 $ 3,471.79 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22551 $ 3,068.89 $ 3,068.89 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22552 $ 712.83 $ 712.83 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22554 $ 2,257.39 $ 2,257.39 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22556 $ 2,999.32 $ 2,999.32 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22558 $ 2,770.98 $ 2,770.98 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22585 $ 590.12 $ 590.12 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22586 $ 3,424.36 $ 3,424.36 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22590 $ 2,830.44 $ 2,830.44 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22595 $ 2,702.67 $ 2,702.67 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22600 $ 2,319.38 $ 2,319.38 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22610 $ 2,276.37 $ 2,276.37 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22612 $ 2,862.06 $ 2,862.06 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22614 $ 702.08 $ 702.08 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22630 $ 2,819.05 $ 2,819.05 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22632 $ 574.94 $ 574.94 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22633 $ 3,332.01 $ 3,332.01 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22634 $ 890.56 $ 890.56 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22800 $ 2,442.72 $ 2,442.72 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

22802 $ 3,791.84 $ 3,791.84 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

22804 $ 4,378.17 $ 4,378.17 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

22808 $ 3,321.89 $ 3,321.89 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

22810 $ 3,681.15 $ 3,681.15 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

22812 $ 3,992.34 $ 3,992.34 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


22818 $ 3,963.88 $ 3,963.88 90 11% 76% 13% 0 2 0 2 2 2 R Y-UR

22819 $ 4,843.05 $ 4,843.05 90 11% 76% 13% 0 2 0 2 2 2 R Y-UR

22830 $ 1,469.30 $ 1,469.30 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

22840 $ 1,364.30 $ 1,364.30 0 0% 0% 0% 0 0 0 2 1 0 R Y-UR

22841 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B Y-UR

22842 $ 1,369.36 $ 1,369.36 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22843 $ 1,465.50 $ 1,465.50 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22844 $ 1,776.69 $ 1,776.69 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22845 $ 1,308.01 $ 1,308.01 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22846 $ 1,358.61 $ 1,358.61 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22847 $ 1,495.86 $ 1,495.86 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22848 $ 648.31 $ 648.31 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22849 $ 2,338.99 $ 2,338.99 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

22850 $ 1,307.38 $ 1,307.38 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

22852 $ 1,252.35 $ 1,252.35 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

22853 $ 466.15 $ 466.15 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22854 $ 603.41 $ 603.41 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22855 $ 1,991.74 $ 1,991.74 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

22856 $ 2,937.33 $ 2,937.33 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22857 $ 3,223.85 $ 3,223.85 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22858 $ 897.52 $ 897.52 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22859 $ 603.41 $ 603.41 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22861 $ 3,521.13 $ 3,521.13 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22862 $ 3,852.56 $ 3,852.56 90 10% 71% 19% 0 2 0 2 2 2 R Y-UR

22864 $ 3,680.52 $ 3,680.52 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR

22865 $ 3,653.95 $ 3,653.95 90 10% 71% 19% 0 2 0 2 2 2 R Y-UR

22867 $ 1,767.21 $ 1,767.21 090 10% 80% 10% 0 2 0 1 0 0 R Y-UR

22868 $ 436.43 $ 436.43 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

22869 $ 981.64 $ 981.64 090 10% 80% 10% 0 2 0 1 0 0 R Y-UR

22870 $ 254.90 $ 254.90 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR


22900 $ 1,018.33 $ 1,018.33 90 10% 69% 21% 0 2 0 2 1 0 R Y

22901 $ 1,200.49 $ 1,200.49 90 10% 69% 21% 0 2 0 2 1 0 R Y

22902 $ 800.11 $ 598.35 90 10% 69% 21% 0 2 0 2 1 0 R Y

22903 $ 791.26 $ 791.26 90 10% 69% 21% 0 2 0 2 1 0 R Y




23000 $ 1,071.46 $ 672.98 90 10% 69% 21% 0 2 1 2 1 0 R Y

23020 $ 1,251.09 $ 1,251.09 90 10% 69% 21% 0 2 1 2 0 0 R Y

23030 $ 815.93 $ 464.89 10 10% 80% 10% 0 2 0 1 0 0 R Y

23031 $ 788.10 $ 399.11 10 10% 80% 10% 0 2 1 1 0 0 R Y

23035 $ 1,234.01 $ 1,234.01 90 10% 69% 21% 0 2 1 2 0 0 R Y

23040 $ 1,301.69 $ 1,301.69 90 10% 69% 21% 0 2 1 2 1 0 R Y

23044 $ 1,029.71 $ 1,029.71 90 10% 69% 21% 0 2 1 1 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY



23066 $ 1,028.45 $ 651.48 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR

23071 $ 757.74 $ 757.74 90 10% 80% 10% 0 2 1 2 0 0 R

23073 $ 1,254.88 $ 1,254.88 90 10% 69% 21% 0 2 1 2 0 0 R

23075 $ 860.20 $ 593.29 90 10% 80% 10% 0 2 1 1 0 0 R

23076 $ 976.58 $ 976.58 90 10% 69% 21% 0 2 1 1 0 0 R



23100 $ 907.64 $ 907.64 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23101 $ 811.50 $ 811.50 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR

23105 $ 1,156.21 $ 1,156.21 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23106 $ 874.12 $ 874.12 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR

23107 $ 1,201.12 $ 1,201.12 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23120 $ 1,063.23 $ 1,063.23 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23125 $ 1,257.41 $ 1,257.41 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23130 $ 1,107.51 $ 1,107.51 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR

23140 $ 977.21 $ 977.21 90 10% 69% 21% 0 2 1 1 0 0 R Y

23145 $ 1,242.86 $ 1,242.86 90 10% 69% 21% 0 2 1 2 1 0 R Y

23146 $ 1,120.79 $ 1,120.79 90 10% 69% 21% 0 2 1 0 0 0 R Y

23150 $ 1,195.43 $ 1,195.43 90 10% 69% 21% 0 2 1 2 1 0 R Y

23155 $ 1,433.25 $ 1,433.25 90 10% 69% 21% 0 2 1 2 1 0 R Y

23156 $ 1,213.77 $ 1,213.77 90 10% 69% 21% 0 2 1 2 0 0 R Y

23170 $ 1,018.33 $ 1,018.33 90 10% 69% 21% 0 2 1 1 0 0 R Y

23172 $ 1,006.31 $ 1,006.31 90 10% 69% 21% 0 2 1 2 0 0 R Y

23174 $ 1,376.95 $ 1,376.95 90 10% 69% 21% 0 2 1 2 1 0 R Y

23180 $ 1,197.96 $ 1,197.96 90 10% 69% 21% 0 2 1 1 1 0 R Y

23182 $ 1,194.79 $ 1,194.79 90 10% 69% 21% 0 2 1 2 0 0 R Y

23184 $ 1,330.15 $ 1,330.15 90 10% 69% 21% 0 2 1 2 1 0 R Y

23190 $ 1,036.67 $ 1,036.67 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23195 $ 1,368.73 $ 1,368.73 90 10% 69% 21% 0 2 1 2 1 0 R Y




23330 $ 456.67 $ 282.10 10 10% 80% 10% 0 2 1 0 0 0 R

23333 $ 821.62 $ 821.62 90 10% 69% 21% 0 2 1 0 0 0 R Y

23334 $ 1,951.26 $ 1,951.26 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR

23335 $ 2,319.38 $ 2,319.38 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR

23350 $ 241.62 $ 92.98 0 0% 0% 0% 0 2 1 1 0 0 R

23395 $ 2,323.81 $ 2,323.81 90 10% 69% 21% 0 2 0 2 1 0 R Y

23397 $ 2,066.38 $ 2,066.38 90 10% 69% 21% 0 2 0 2 1 0 R Y

23400 $ 1,709.02 $ 1,709.02 90 10% 69% 21% 0 2 1 2 1 0 R Y

23405 $ 1,130.28 $ 1,130.28 90 10% 69% 21% 0 2 0 2 1 0 R Y

23406 $ 1,395.93 $ 1,395.93 90 10% 69% 21% 0 2 0 2 0 0 R Y

23410 $ 1,490.80 $ 1,490.80 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23412 $ 1,544.57 $ 1,544.57 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


23415 $ 1,265.63 $ 1,265.63 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR

23420 $ 1,757.72 $ 1,757.72 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23430 $ 1,353.55 $ 1,353.55 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23440 $ 1,367.47 $ 1,367.47 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23450 $ 1,717.87 $ 1,717.87 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23455 $ 1,801.99 $ 1,801.99 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23460 $ 1,968.97 $ 1,968.97 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23462 $ 1,911.42 $ 1,911.42 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23465 $ 2,013.88 $ 2,013.88 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23466 $ 2,030.33 $ 2,030.33 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23470 $ 2,176.43 $ 2,176.43 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23472 $ 2,638.16 $ 2,638.16 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23473 $ 2,943.66 $ 2,943.66 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23474 $ 3,178.31 $ 3,178.31 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23480 $ 1,484.48 $ 1,484.48 90 10% 69% 21% 0 2 1 1 1 0 R

23485 $ 1,725.46 $ 1,725.46 90 10% 69% 21% 0 2 1 2 1 0 R Y

23490 $ 1,515.47 $ 1,515.47 90 10% 69% 21% 0 2 1 2 0 0 R Y

23491 $ 1,831.72 $ 1,831.72 90 10% 69% 21% 0 2 1 2 1 0 R

23500 $ 399.11 $ 405.43 90 10% 69% 21% 0 2 1 1 0 0 R

23505 $ 638.19 $ 601.51 90 10% 69% 21% 0 2 1 1 0 0 R

23515 $ 1,308.01 $ 1,308.01 90 10% 69% 21% 0 2 1 2 1 0 R

23520 $ 417.45 $ 423.78 90 10% 69% 21% 0 2 1 0 0 0 R

23525 $ 680.57 $ 628.71 90 10% 69% 21% 0 2 1 0 0 0 R

23530 $ 1,034.77 $ 1,034.77 90 10% 69% 21% 0 2 1 2 0 0 R

23532 $ 1,127.12 $ 1,127.12 90 10% 69% 21% 0 2 1 2 0 0 R

23540 $ 409.23 $ 415.55 90 10% 69% 21% 0 2 1 1 0 0 R

23545 $ 616.06 $ 559.13 90 10% 69% 21% 0 2 1 0 0 0 R

23550 $ 1,017.69 $ 1,017.69 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23552 $ 1,189.10 $ 1,189.10 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

23570 $ 423.14 $ 437.06 90 10% 69% 21% 0 2 1 1 0 0 R

23575 $ 724.85 $ 678.67 90 10% 69% 21% 0 2 1 0 0 0 R

23585 $ 1,775.43 $ 1,775.43 90 10% 69% 21% 0 2 1 2 1 0 R

23600 $ 597.08 $ 561.66 90 10% 69% 21% 0 2 1 1 0 0 R

23605 $ 843.12 $ 769.75 90 10% 69% 21% 0 2 1 1 0 0 R

23615 $ 1,604.65 $ 1,604.65 90 10% 69% 21% 0 2 1 2 1 0 R

23616 $ 2,249.17 $ 2,249.17 90 10% 69% 21% 0 2 1 2 2 0 R

23620 $ 492.09 $ 468.05 90 10% 69% 21% 0 2 1 1 0 0 R

23625 $ 687.53 $ 638.19 90 10% 69% 21% 0 2 1 1 0 0 R

23630 $ 1,416.17 $ 1,416.17 90 10% 69% 21% 0 2 1 2 1 0 R

23650 $ 572.41 $ 524.34 90 10% 69% 21% 0 2 1 1 0 0 R

23655 $ 729.91 $ 729.91 90 10% 69% 21% 0 2 1 1 0 0 R

23660 $ 1,055.64 $ 1,055.64 90 10% 69% 21% 0 2 1 2 1 0 R

23665 $ 774.81 $ 719.15 90 10% 69% 21% 0 2 1 1 0 0 R

23670 $ 1,588.21 $ 1,588.21 90 10% 69% 21% 0 2 1 2 1 0 R

23675 $ 998.09 $ 907.01 90 10% 69% 21% 0 2 1 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


23680 $ 1,678.02 $ 1,678.02 90 10% 69% 21% 0 2 1 2 1 0 R

23700 $ 356.10 $ 356.10 10 10% 80% 10% 0 2 1 1 0 0 R

23800 $ 1,841.84 $ 1,841.84 90 10% 69% 21% 0 2 1 2 1 0 R Y

23802 $ 2,319.38 $ 2,319.38 90 10% 69% 21% 0 2 1 2 1 0 R Y

23900 $ 2,512.29 $ 2,512.29 90 10% 69% 21% 0 2 0 2 0 0 R Y

23920 $ 1,996.17 $ 1,996.17 90 10% 69% 21% 0 2 1 2 1 0 R Y

23921 $ 849.45 $ 849.45 90 10% 69% 21% 0 2 1 1 0 0 R Y


23930 $ 651.48 $ 391.52 10 10% 80% 10% 0 2 1 1 0 0 R

23931 $ 531.93 $ 292.22 10 10% 80% 10% 0 2 1 1 0 0 R

23935 $ 920.92 $ 920.92 90 10% 69% 21% 0 2 1 0 0 0 R

24000 $ 869.06 $ 869.06 90 10% 69% 21% 0 2 1 0 1 0 R Y-UR

24006 $ 1,291.57 $ 1,291.57 90 10% 69% 21% 0 2 1 2 2 0 R Y-UR

24065 $ 473.74 $ 308.03 10 10% 80% 10% 0 2 1 1 0 0 R

24066 $ 1,146.72 $ 754.57 90 10% 69% 21% 0 2 1 1 0 0 R

24071 $ 733.70 $ 733.70 90 10% 69% 21% 0 2 1 2 0 0 R

24073 $ 1,251.09 $ 1,251.09 90 10% 69% 21% 0 2 1 2 0 0 R

24075 $ 900.68 $ 600.24 90 10% 69% 21% 0 2 1 1 0 0 R

24076 $ 984.17 $ 984.17 90 10% 69% 21% 0 2 1 1 0 0 R



24100 $ 755.21 $ 755.21 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24101 $ 905.11 $ 905.11 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

24102 $ 1,118.89 $ 1,118.89 90 10% 69% 21% 0 2 1 2 1 0 R

24105 $ 640.09 $ 640.09 90 10% 69% 21% 0 2 1 1 0 0 R

24110 $ 1,057.54 $ 1,057.54 90 10% 69% 21% 0 2 1 1 1 0 R

24115 $ 1,320.66 $ 1,320.66 90 10% 69% 21% 0 2 1 2 1 0 R

24116 $ 1,561.64 $ 1,561.64 90 10% 69% 21% 0 2 1 2 0 0 R

24120 $ 961.40 $ 961.40 90 10% 69% 21% 0 2 1 0 0 0 R

24125 $ 1,119.53 $ 1,119.53 90 10% 69% 21% 0 2 1 2 1 0 R

24126 $ 1,169.49 $ 1,169.49 90 10% 69% 21% 0 2 1 2 0 0 R

24130 $ 922.82 $ 922.82 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR

24134 $ 1,355.45 $ 1,355.45 90 10% 69% 21% 0 2 1 2 0 0 R

24136 $ 1,078.41 $ 1,078.41 90 10% 69% 21% 0 2 1 1 0 0 R

24138 $ 1,225.15 $ 1,225.15 90 10% 69% 21% 0 2 1 2 0 0 R

24140 $ 1,275.75 $ 1,275.75 90 10% 69% 21% 0 2 1 2 0 0 R

24145 $ 1,060.70 $ 1,060.70 90 10% 69% 21% 0 2 1 1 1 0 R

24147 $ 1,132.81 $ 1,132.81 90 10% 69% 21% 0 2 1 1 1 0 R

24149 $ 2,135.32 $ 2,135.32 90 10% 69% 21% 0 2 1 2 1 0 R



24155 $ 1,546.46 $ 1,546.46 90 10% 69% 21% 0 2 1 2 1 0 R

24160 $ 2,295.34 $ 2,295.34 90 10% 69% 21% 0 2 1 1 1 0 R

24164 $ 1,323.82 $ 1,323.82 90 10% 69% 21% 0 2 1 1 1 0 R

24200 $ 380.77 $ 254.90 10 10% 80% 10% 0 2 1 0 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


24201 $ 1,006.31 $ 657.17 90 10% 69% 21% 0 2 1 1 0 0 R

24220 $ 294.11 $ 125.24 0 0% 0% 0% 0 2 1 0 0 0 R

24300 $ 762.80 $ 762.80 90 10% 69% 21% 0 2 1 1 0 0 R

24301 $ 1,360.51 $ 1,360.51 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

24305 $ 1,049.32 $ 1,049.32 90 10% 69% 21% 0 2 0 0 0 0 R Y-UR

24310 $ 852.61 $ 852.61 90 10% 69% 21% 0 2 0 0 0 0 R Y-UR

24320 $ 1,384.54 $ 1,384.54 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR

24330 $ 1,299.16 $ 1,299.16 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

24331 $ 1,416.80 $ 1,416.80 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

24332 $ 1,112.57 $ 1,112.57 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR

24340 $ 1,113.20 $ 1,113.20 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24341 $ 1,357.98 $ 1,357.98 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24342 $ 1,406.68 $ 1,406.68 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24343 $ 1,286.51 $ 1,286.51 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24344 $ 1,978.46 $ 1,978.46 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24345 $ 1,280.18 $ 1,280.18 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24346 $ 1,991.11 $ 1,991.11 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24357 $ 770.39 $ 770.39 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR

24358 $ 950.65 $ 950.65 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR

24359 $ 1,197.32 $ 1,197.32 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR

24360 $ 1,629.32 $ 1,629.32 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24361 $ 1,816.54 $ 1,816.54 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24362 $ 1,922.17 $ 1,922.17 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

24363 $ 2,639.42 $ 2,639.42 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

24365 $ 1,157.48 $ 1,157.48 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24366 $ 1,235.27 $ 1,235.27 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24370 $ 2,811.46 $ 2,811.46 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

24371 $ 3,230.81 $ 3,230.81 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

24400 $ 1,485.11 $ 1,485.11 90 10% 69% 21% 0 2 1 2 1 0 R


24420 $ 1,789.98 $ 1,789.98 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24430 $ 1,917.11 $ 1,917.11 90 10% 69% 21% 0 2 1 2 1 0 R

24435 $ 1,953.79 $ 1,953.79 90 10% 69% 21% 0 2 1 2 1 0 R

24470 $ 1,216.93 $ 1,216.93 90 10% 69% 21% 0 2 1 2 0 0 R Y

24495 $ 951.91 $ 951.91 90 10% 69% 21% 0 2 1 0 0 0 R

24498 $ 1,566.07 $ 1,566.07 90 10% 69% 21% 0 2 1 2 1 0 R

24500 $ 655.27 $ 595.18 90 10% 69% 21% 0 2 1 1 0 0 R

24505 $ 908.27 $ 818.46 90 10% 69% 21% 0 2 1 1 0 0 R

24515 $ 1,590.11 $ 1,590.11 90 10% 69% 21% 0 2 1 2 1 0 R

24516 $ 1,557.22 $ 1,557.22 90 10% 69% 21% 0 2 1 2 2 0 R

24530 $ 695.12 $ 627.44 90 10% 69% 21% 0 2 1 1 0 0 R

24535 $ 1,115.73 $ 1,028.45 90 10% 69% 21% 0 2 1 1 0 0 R

24538 $ 1,352.29 $ 1,352.29 90 10% 69% 21% 0 2 1 1 0 0 R

24545 $ 1,684.98 $ 1,684.98 90 10% 69% 21% 0 2 1 2 1 0 R

24546 $ 1,884.22 $ 1,884.22 90 10% 69% 21% 0 2 1 2 2 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


24560 $ 586.96 $ 524.98 90 10% 69% 21% 0 2 1 1 0 0 R

24565 $ 967.09 $ 885.50 90 10% 69% 21% 0 2 1 1 0 0 R

24566 $ 1,304.85 $ 1,304.85 90 10% 69% 21% 0 2 1 1 0 0 R

24575 $ 1,333.31 $ 1,333.31 90 10% 69% 21% 0 2 1 2 1 0 R

24576 $ 622.38 $ 557.87 90 10% 69% 21% 0 2 1 1 0 0 R

24577 $ 989.86 $ 905.74 90 10% 69% 21% 0 2 1 1 0 0 R

24579 $ 1,516.74 $ 1,516.74 90 10% 69% 21% 0 2 1 2 1 0 R

24582 $ 1,471.20 $ 1,471.20 90 10% 69% 21% 0 2 1 1 0 0 R

24586 $ 1,960.75 $ 1,960.75 90 10% 69% 21% 0 2 1 2 1 0 R

24587 $ 1,960.75 $ 1,960.75 90 10% 69% 21% 0 2 1 2 1 0 R

24600 $ 661.60 $ 604.67 90 10% 69% 21% 0 2 1 1 0 0 R

24605 $ 853.24 $ 853.24 90 10% 69% 21% 0 2 1 1 0 0 R

24615 $ 1,292.20 $ 1,292.20 90 10% 69% 21% 0 2 1 2 1 0 R

24620 $ 996.82 $ 996.82 90 10% 69% 21% 0 2 1 0 0 0 R

24635 $ 1,222.62 $ 1,222.62 90 10% 69% 21% 0 2 1 2 1 0 R


24650 $ 479.44 $ 439.59 90 10% 69% 21% 0 2 1 1 0 0 R

24655 $ 795.05 $ 721.68 90 10% 69% 21% 0 2 1 1 0 0 R

24665 $ 1,187.20 $ 1,187.20 90 10% 69% 21% 0 2 1 2 1 0 R

24666 $ 1,331.41 $ 1,331.41 90 10% 69% 21% 0 2 1 2 1 0 R

24670 $ 531.93 $ 479.44 90 10% 69% 21% 0 2 1 1 0 0 R

24675 $ 822.25 $ 748.25 90 10% 69% 21% 0 2 1 1 0 0 R

24685 $ 1,188.47 $ 1,188.47 90 10% 69% 21% 0 2 1 2 1 0 R

24800 $ 1,504.09 $ 1,504.09 90 10% 69% 21% 0 2 1 2 1 0 R

24802 $ 1,795.04 $ 1,795.04 90 10% 69% 21% 0 2 1 2 0 0 R

24900 $ 1,324.46 $ 1,324.46 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24920 $ 1,306.11 $ 1,306.11 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

24925 $ 932.94 $ 932.94 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

24930 $ 1,375.69 $ 1,375.69 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

24931 $ 1,455.38 $ 1,455.38 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

24935 $ 1,726.73 $ 1,726.73 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR

24940 $ 1,834.11 $ 1,834.11 90 10% 69% 21% 0 2 1 2 0 0 F Y-UR


25000 $ 615.42 $ 615.42 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR

25001 $ 628.07 $ 628.07 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR

25020 $ 1,051.22 $ 1,051.22 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR

25023 $ 2,001.86 $ 2,001.86 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR

25024 $ 1,405.42 $ 1,405.42 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR

25025 $ 2,213.12 $ 2,213.12 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR

25028 $ 958.24 $ 958.24 90 10% 69% 21% 0 2 1 1 0 0 R

25031 $ 660.96 $ 660.96 90 10% 69% 21% 0 2 1 0 0 0 R

25035 $ 1,058.17 $ 1,058.17 90 10% 69% 21% 0 2 1 0 0 0 R

25040 $ 1,022.12 $ 1,022.12 90 10% 69% 21% 0 2 1 0 0 0 R

25065 $ 468.68 $ 299.81 10 10% 80% 10% 0 2 1 1 0 0 R

25066 $ 655.27 $ 655.27 90 10% 69% 21% 0 2 1 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


25071 $ 770.39 $ 770.39 90 10% 69% 21% 0 2 1 2 0 0 R

25073 $ 968.99 $ 968.99 90 10% 69% 21% 0 2 1 2 0 0 R

25075 $ 877.91 $ 575.58 90 10% 69% 21% 0 2 1 1 0 0 R

25076 $ 941.79 $ 941.79 90 10% 69% 21% 0 2 1 1 0 0 R



25085 $ 815.29 $ 815.29 90 10% 69% 21% 0 2 1 2 0 0 R

25100 $ 614.79 $ 614.79 90 10% 69% 21% 0 2 1 0 0 0 R

25101 $ 735.60 $ 735.60 90 10% 69% 21% 0 2 1 0 0 0 R

25105 $ 877.91 $ 877.91 90 10% 69% 21% 0 2 1 0 1 0 R

25107 $ 1,122.69 $ 1,122.69 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

25109 $ 979.74 $ 979.74 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR

25110 $ 622.38 $ 622.38 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR

25111 $ 585.06 $ 585.06 90 10% 69% 21% 0 2 1 1 0 0 R

25112 $ 704.61 $ 704.61 90 10% 69% 21% 0 2 1 1 0 0 R

25115 $ 1,380.12 $ 1,380.12 90 10% 69% 21% 0 2 1 1 0 0 R

25116 $ 1,093.59 $ 1,093.59 90 10% 69% 21% 0 2 1 0 1 0 R

25118 $ 695.12 $ 695.12 90 10% 69% 21% 0 2 1 1 0 0 R

25119 $ 898.78 $ 898.78 90 10% 69% 21% 0 2 1 2 1 0 R

25120 $ 905.11 $ 905.11 90 10% 69% 21% 0 2 1 0 1 0 R

25125 $ 1,075.88 $ 1,075.88 90 10% 69% 21% 0 2 1 0 0 0 R

25126 $ 1,067.03 $ 1,067.03 90 10% 69% 21% 0 2 1 2 0 0 R

25130 $ 812.76 $ 812.76 90 10% 69% 21% 0 2 1 0 0 0 R

25135 $ 1,013.27 $ 1,013.27 90 10% 69% 21% 0 2 1 2 1 0 R

25136 $ 884.87 $ 884.87 90 10% 69% 21% 0 2 1 2 1 0 R

25145 $ 939.26 $ 939.26 90 10% 69% 21% 0 2 1 2 0 0 R

25150 $ 1,024.65 $ 1,024.65 90 10% 69% 21% 0 2 1 1 1 0 R

25151 $ 1,058.81 $ 1,058.81 90 10% 69% 21% 0 2 1 2 1 0 R


25210 $ 888.03 $ 888.03 90 10% 69% 21% 0 2 0 0 1 0 R

25215 $ 1,123.95 $ 1,123.95 90 10% 69% 21% 0 2 1 2 1 0 R

25230 $ 787.46 $ 787.46 90 10% 69% 21% 0 2 1 1 1 0 R

25240 $ 780.51 $ 780.51 90 10% 69% 21% 0 2 1 0 1 0 R

25246 $ 298.54 $ 137.25 0 0% 0% 0% 0 2 1 1 0 0 R

25248 $ 746.35 $ 746.35 90 10% 69% 21% 0 2 1 1 0 0 R

25250 $ 962.67 $ 962.67 90 10% 69% 21% 0 2 1 2 0 0 R

25251 $ 1,301.69 $ 1,301.69 90 10% 69% 21% 0 2 1 2 0 0 R

25259 $ 761.53 $ 761.53 90 10% 69% 21% 0 2 1 1 0 0 R

25260 $ 1,145.46 $ 1,145.46 90 10% 69% 21% 0 2 0 1 0 0 R

25263 $ 1,132.18 $ 1,132.18 90 10% 69% 21% 0 2 0 2 0 0 R

25265 $ 1,356.08 $ 1,356.08 90 10% 69% 21% 0 2 0 2 0 0 R

25270 $ 891.83 $ 891.83 90 10% 69% 21% 0 2 0 0 0 0 R

25272 $ 1,005.68 $ 1,005.68 90 10% 69% 21% 0 2 0 0 0 0 R

25274 $ 1,203.65 $ 1,203.65 90 10% 69% 21% 0 2 0 0 1 0 R

25275 $ 1,218.20 $ 1,218.20 90 10% 69% 21% 0 2 1 0 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


25280 $ 1,025.28 $ 1,025.28 90 10% 69% 21% 0 2 0 0 1 0 R

25290 $ 794.42 $ 794.42 90 10% 69% 21% 0 2 0 1 0 0 R

25295 $ 953.81 $ 953.81 90 10% 69% 21% 0 2 0 1 0 0 R

25300 $ 1,235.27 $ 1,235.27 90 10% 69% 21% 0 2 1 2 0 0 R

25301 $ 1,168.23 $ 1,168.23 90 10% 69% 21% 0 2 1 2 0 0 R

25310 $ 1,127.12 $ 1,127.12 90 10% 69% 21% 0 2 0 2 1 0 R

25312 $ 1,302.95 $ 1,302.95 90 10% 69% 21% 0 2 0 2 1 0 R

25315 $ 1,395.93 $ 1,395.93 90 10% 69% 21% 0 2 1 2 0 0 R

25316 $ 1,650.19 $ 1,650.19 90 10% 69% 21% 0 2 1 2 0 0 R

25320 $ 1,796.93 $ 1,796.93 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

25332 $ 1,528.12 $ 1,528.12 90 10% 69% 21% 0 2 1 2 0 0 R


25337 $ 1,621.73 $ 1,621.73 90 10% 69% 21% 0 2 1 1 0 0 R

25350 $ 1,223.89 $ 1,223.89 90 10% 69% 21% 0 2 1 2 0 0 R

25355 $ 1,381.38 $ 1,381.38 90 10% 69% 21% 0 2 1 2 0 0 R

25360 $ 1,186.57 $ 1,186.57 90 10% 69% 21% 0 2 1 2 1 0 R

25365 $ 1,657.78 $ 1,657.78 90 10% 69% 21% 0 2 1 2 0 0 R

25370 $ 1,822.87 $ 1,822.87 90 10% 69% 21% 0 2 1 2 0 0 R

25375 $ 1,725.46 $ 1,725.46 90 10% 69% 21% 0 2 1 2 1 0 R

25390 $ 1,399.09 $ 1,399.09 90 10% 69% 21% 0 2 1 2 1 0 R

25391 $ 1,802.63 $ 1,802.63 90 10% 69% 21% 0 2 1 2 1 0 R

25392 $ 1,855.12 $ 1,855.12 90 10% 69% 21% 0 2 1 2 0 0 R

25393 $ 2,049.30 $ 2,049.30 90 10% 69% 21% 0 2 1 2 0 0 R

25394 $ 1,428.82 $ 1,428.82 90 10% 69% 21% 0 2 1 2 1 0 R

25400 $ 1,457.28 $ 1,457.28 90 10% 69% 21% 0 2 1 2 1 0 R

25405 $ 1,879.79 $ 1,879.79 90 10% 69% 21% 0 2 1 2 1 0 R

25415 $ 1,751.39 $ 1,751.39 90 10% 69% 21% 0 2 1 2 1 0 R

25420 $ 2,103.70 $ 2,103.70 90 10% 69% 21% 0 2 1 2 1 0 R

25425 $ 1,743.17 $ 1,743.17 90 10% 69% 21% 0 2 1 2 1 0 R

25426 $ 1,990.48 $ 1,990.48 90 10% 69% 21% 0 2 1 2 1 0 R

25430 $ 1,327.62 $ 1,327.62 90 10% 69% 21% 0 2 1 1 0 0 R

25431 $ 1,436.41 $ 1,436.41 90 10% 69% 21% 0 2 1 2 1 0 R

25440 $ 1,397.19 $ 1,397.19 90 10% 69% 21% 0 2 1 2 1 0 R

25441 $ 1,704.59 $ 1,704.59 90 10% 69% 21% 0 2 1 2 1 0 R

25442 $ 1,464.87 $ 1,464.87 90 10% 69% 21% 0 2 1 2 1 0 R

25443 $ 1,401.62 $ 1,401.62 90 10% 69% 21% 0 2 1 2 1 0 R

25444 $ 1,487.64 $ 1,487.64 90 10% 69% 21% 0 2 1 2 0 0 R

25445 $ 1,310.54 $ 1,310.54 90 10% 69% 21% 0 2 1 1 1 0 R

25446 $ 2,127.73 $ 2,127.73 90 10% 69% 21% 0 2 1 2 1 0 R

25447 $ 1,506.62 $ 1,506.62 90 10% 69% 21% 0 2 1 2 1 0 R

25449 $ 1,874.73 $ 1,874.73 90 10% 69% 21% 0 2 1 2 1 0 R

25450 $ 941.79 $ 941.79 90 10% 69% 21% 0 2 1 1 0 0 R Y

25455 $ 1,315.60 $ 1,315.60 90 10% 69% 21% 0 2 1 1 0 0 R Y

25490 $ 1,303.58 $ 1,303.58 90 10% 69% 21% 0 2 1 2 0 0 R

25491 $ 1,340.27 $ 1,340.27 90 10% 69% 21% 0 2 1 2 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


25492 $ 1,637.54 $ 1,637.54 90 10% 69% 21% 0 2 1 2 0 0 R

25500 $ 500.31 $ 458.56 90 10% 69% 21% 0 2 1 1 0 0 R

25505 $ 911.43 $ 832.37 90 10% 69% 21% 0 2 1 1 0 0 R

25515 $ 1,214.40 $ 1,214.40 90 10% 69% 21% 0 2 1 2 1 0 R

25520 $ 1,025.28 $ 970.89 90 10% 69% 21% 0 2 1 1 0 0 R

25525 $ 1,425.02 $ 1,425.02 90 10% 69% 21% 0 2 1 2 2 0 R

25526 $ 1,726.09 $ 1,726.09 90 10% 69% 21% 0 2 1 2 2 0 R

25530 $ 480.07 $ 433.90 90 10% 69% 21% 0 2 1 1 0 0 R

25535 $ 888.66 $ 820.99 90 10% 69% 21% 0 2 1 1 0 0 R

25545 $ 1,133.44 $ 1,133.44 90 10% 69% 21% 0 2 1 2 1 0 R

25560 $ 508.53 $ 459.20 90 10% 69% 21% 0 2 1 1 0 0 R

25565 $ 941.16 $ 848.18 90 10% 69% 21% 0 2 1 1 0 0 R

25574 $ 1,224.52 $ 1,224.52 90 10% 69% 21% 0 2 1 2 2 0 R

25575 $ 1,635.01 $ 1,635.01 90 10% 69% 21% 0 2 1 2 1 0 R

25600 $ 602.14 $ 568.62 90 10% 69% 21% 0 2 1 1 0 0 R

25605 $ 988.60 $ 928.51 90 10% 69% 21% 0 2 1 1 0 0 R

25606 $ 1,204.91 $ 1,204.91 90 10% 69% 21% 0 2 1 1 0 0 R

25607 $ 1,335.84 $ 1,335.84 90 10% 69% 21% 0 2 1 2 0 0 R

25608 $ 1,496.50 $ 1,496.50 90 10% 69% 21% 0 2 1 2 0 0 R

25609 $ 1,901.93 $ 1,901.93 90 10% 69% 21% 0 2 1 2 0 0 R

25622 $ 557.87 $ 507.90 90 10% 69% 21% 0 2 1 1 0 0 R

25624 $ 869.06 $ 790.63 90 10% 69% 21% 0 2 1 0 0 0 R

25628 $ 1,309.91 $ 1,309.91 90 10% 69% 21% 0 2 1 2 0 0 R

25630 $ 557.87 $ 511.69 90 10% 69% 21% 0 2 1 1 0 0 R

25635 $ 767.86 $ 686.26 90 10% 69% 21% 0 2 1 0 0 0 R

25645 $ 1,025.28 $ 1,025.28 90 10% 69% 21% 0 2 1 2 0 0 R

25650 $ 583.17 $ 546.48 90 10% 69% 21% 0 2 1 1 0 0 R

25651 $ 881.07 $ 881.07 90 10% 69% 21% 0 2 1 0 0 0 R

25652 $ 1,132.81 $ 1,132.81 90 10% 69% 21% 0 2 1 1 1 0 R

25660 $ 748.88 $ 748.88 90 10% 69% 21% 0 2 1 0 0 0 R

25670 $ 1,099.92 $ 1,099.92 90 10% 69% 21% 0 2 1 2 1 0 R

25671 $ 964.56 $ 964.56 90 10% 69% 21% 0 2 1 1 0 0 R

25675 $ 788.10 $ 715.99 90 10% 69% 21% 0 2 1 0 0 0 R

25676 $ 1,141.03 $ 1,141.03 90 10% 69% 21% 0 2 1 2 0 0 R

25680 $ 872.22 $ 872.22 90 10% 69% 21% 0 2 1 0 0 0 R

25685 $ 1,328.25 $ 1,328.25 90 10% 69% 21% 0 2 1 2 0 0 R

25690 $ 859.57 $ 859.57 90 10% 69% 21% 0 2 1 0 0 0 R

25695 $ 1,147.36 $ 1,147.36 90 10% 69% 21% 0 2 1 2 1 0 R

25800 $ 1,330.15 $ 1,330.15 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

25805 $ 1,530.65 $ 1,530.65 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

25810 $ 1,578.72 $ 1,578.72 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

25820 $ 1,120.79 $ 1,120.79 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

25825 $ 1,380.75 $ 1,380.75 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

25830 $ 1,724.20 $ 1,724.20 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

25900 $ 1,285.24 $ 1,285.24 90 10% 69% 21% 0 2 1 0 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


25905 $ 1,271.33 $ 1,271.33 90 10% 69% 21% 0 2 1 2 0 0 R

25907 $ 1,106.24 $ 1,106.24 90 10% 69% 21% 0 2 1 2 0 0 R

25909 $ 1,235.91 $ 1,235.91 90 10% 69% 21% 0 2 1 2 0 0 R

25915 $ 1,839.31 $ 1,839.31 90 10% 69% 21% 0 2 1 2 0 0 R

25920 $ 1,263.10 $ 1,263.10 90 10% 69% 21% 0 2 1 0 0 0 R

25922 $ 927.25 $ 927.25 90 10% 69% 21% 0 2 1 2 0 0 R

25924 $ 1,215.03 $ 1,215.03 90 10% 69% 21% 0 2 1 2 0 0 R

25927 $ 1,469.93 $ 1,469.93 90 10% 69% 21% 0 2 1 0 0 0 R

25929 $ 1,030.98 $ 1,030.98 90 10% 69% 21% 0 2 1 2 0 0 R

25931 $ 1,321.93 $ 1,321.93 90 10% 69% 21% 0 2 1 1 0 0 R


26010 $ 490.82 $ 251.74 10 10% 80% 10% 0 2 0 1 0 0 R

26011 $ 722.95 $ 337.12 10 10% 80% 10% 0 2 0 1 0 0 R

26020 $ 789.99 $ 789.99 90 10% 69% 21% 0 2 0 1 0 0 R

26025 $ 769.75 $ 769.75 90 10% 69% 21% 0 2 1 0 0 0 R

26030 $ 896.89 $ 896.89 90 10% 69% 21% 0 2 1 0 0 0 R

26034 $ 981.64 $ 981.64 90 10% 69% 21% 0 2 0 1 0 0 R

26035 $ 1,553.42 $ 1,553.42 90 10% 69% 21% 0 2 0 0 0 0 R

26037 $ 1,027.18 $ 1,027.18 90 10% 69% 21% 0 2 1 0 0 0 R

26040 $ 569.88 $ 569.88 90 10% 69% 21% 0 2 1 1 0 0 R

26045 $ 851.35 $ 851.35 90 10% 69% 21% 0 2 1 1 0 0 R

26055 $ 1,034.14 $ 567.99 90 10% 69% 21% 0 2 0 1 0 0 R

26060 $ 476.27 $ 476.27 90 10% 69% 21% 0 2 0 0 0 0 R

26070 $ 575.58 $ 575.58 90 10% 69% 21% 0 2 1 1 0 0 R

26075 $ 607.20 $ 607.20 90 10% 69% 21% 0 2 1 1 0 0 R

26080 $ 711.56 $ 711.56 90 10% 69% 21% 0 2 0 1 0 0 R

26100 $ 591.39 $ 591.39 90 10% 69% 21% 0 2 1 0 0 0 R

26105 $ 607.83 $ 607.83 90 10% 69% 21% 0 2 1 0 0 0 R

26110 $ 587.59 $ 587.59 90 10% 69% 21% 0 2 0 1 0 0 R

26111 $ 760.27 $ 760.27 90 10% 69% 21% 0 2 0 2 0 0 R

26113 $ 999.35 $ 999.35 90 10% 69% 21% 0 2 0 2 0 0 R

26115 $ 927.88 $ 606.57 90 10% 69% 21% 0 2 0 1 0 0 R

26116 $ 959.50 $ 959.50 90 10% 69% 21% 0 2 0 1 0 0 R



26121 $ 1,086.00 $ 1,086.00 90 10% 69% 21% 0 2 1 1 0 0 R

26123 $ 1,518.63 $ 1,518.63 90 10% 69% 21% 0 2 1 1 0 0 R

26125 $ 495.88 $ 495.88 0 0% 0% 0% 0 0 0 1 0 0 R

26130 $ 839.96 $ 839.96 90 10% 69% 21% 0 2 1 1 0 0 R

26135 $ 999.98 $ 999.98 90 10% 69% 21% 0 2 0 0 0 0 R

26140 $ 917.76 $ 917.76 90 10% 69% 21% 0 2 0 1 0 0 R

26145 $ 932.31 $ 932.31 90 10% 69% 21% 0 2 0 1 0 0 R

26160 $ 1,061.34 $ 610.36 90 10% 69% 21% 0 2 0 1 0 0 R

26170 $ 740.66 $ 740.66 90 10% 69% 21% 0 2 0 0 0 0 R

26180 $ 807.70 $ 807.70 90 10% 69% 21% 0 2 0 0 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


26185 $ 995.56 $ 995.56 90 10% 69% 21% 0 2 1 2 1 0 R

26200 $ 817.19 $ 817.19 90 10% 69% 21% 0 2 0 0 0 0 R

26205 $ 1,080.31 $ 1,080.31 90 10% 69% 21% 0 2 0 1 0 0 R

26210 $ 805.81 $ 805.81 90 10% 69% 21% 0 2 0 1 0 0 R

26215 $ 1,013.90 $ 1,013.90 90 10% 69% 21% 0 2 0 1 0 0 R

26230 $ 908.90 $ 908.90 90 10% 69% 21% 0 2 0 0 0 0 R

26235 $ 895.62 $ 895.62 90 10% 69% 21% 0 2 0 0 0 0 R

26236 $ 802.01 $ 802.01 90 10% 69% 21% 0 2 0 1 0 0 R

26250 $ 1,963.91 $ 1,963.91 90 10% 69% 21% 0 2 0 0 0 0 R

26260 $ 1,456.02 $ 1,456.02 90 10% 69% 21% 0 2 0 2 0 0 R

26262 $ 1,142.30 $ 1,142.30 90 10% 69% 21% 0 2 0 2 0 0 R

26320 $ 632.50 $ 632.50 90 10% 69% 21% 0 2 0 1 0 0 R

26340 $ 614.16 $ 614.16 90 10% 69% 21% 0 2 1 1 0 0 R

26341 $ 180.90 $ 136.62 10 10% 80% 10% 0 2 1 1 0 0 R

26350 $ 1,294.10 $ 1,294.10 90 10% 69% 21% 0 2 0 1 0 0 R

26352 $ 1,455.38 $ 1,455.38 90 10% 69% 21% 0 2 0 2 1 0 R

26356 $ 1,447.79 $ 1,447.79 90 10% 69% 21% 0 2 0 1 0 0 R

26357 $ 1,612.24 $ 1,612.24 90 10% 69% 21% 0 2 0 2 0 0 R

26358 $ 1,783.02 $ 1,783.02 90 10% 69% 21% 0 2 0 2 0 0 R

26370 $ 1,373.79 $ 1,373.79 90 10% 69% 21% 0 2 0 0 0 0 R

26372 $ 1,557.85 $ 1,557.85 90 10% 69% 21% 0 2 0 2 0 0 R

26373 $ 1,514.84 $ 1,514.84 90 10% 69% 21% 0 2 0 2 0 0 R

26390 $ 1,506.62 $ 1,506.62 90 10% 69% 21% 0 2 0 2 1 0 R

26392 $ 1,753.29 $ 1,753.29 90 10% 69% 21% 0 2 0 2 1 0 R

26410 $ 1,026.55 $ 1,026.55 90 10% 69% 21% 0 2 0 1 0 0 R

26412 $ 1,252.98 $ 1,252.98 90 10% 69% 21% 0 2 0 0 0 0 R

26415 $ 1,242.86 $ 1,242.86 90 10% 69% 21% 0 2 0 0 0 0 R

26416 $ 1,563.54 $ 1,563.54 90 10% 69% 21% 0 2 0 1 0 0 R

26418 $ 1,052.48 $ 1,052.48 90 10% 69% 21% 0 2 0 1 0 0 R

26420 $ 1,279.55 $ 1,279.55 90 10% 69% 21% 0 2 0 2 0 0 R

26426 $ 911.43 $ 911.43 90 10% 69% 21% 0 2 0 1 0 0 R

26428 $ 1,344.70 $ 1,344.70 90 10% 69% 21% 0 2 0 0 0 0 R

26432 $ 906.37 $ 906.37 90 10% 69% 21% 0 2 0 1 0 0 R

26433 $ 960.77 $ 960.77 90 10% 69% 21% 0 2 0 1 0 0 R

26434 $ 1,169.49 $ 1,169.49 90 10% 69% 21% 0 2 0 2 0 0 R

26437 $ 1,127.75 $ 1,127.75 90 10% 69% 21% 0 2 0 1 0 0 R

26440 $ 1,125.85 $ 1,125.85 90 10% 69% 21% 0 2 0 1 0 0 R

26442 $ 1,750.13 $ 1,750.13 90 10% 69% 21% 0 2 0 1 0 0 R

26445 $ 1,049.95 $ 1,049.95 90 10% 69% 21% 0 2 0 1 0 0 R

26449 $ 1,266.27 $ 1,266.27 90 10% 69% 21% 0 2 0 0 0 0 R

26450 $ 735.60 $ 735.60 90 10% 69% 21% 0 2 0 0 0 0 R

26455 $ 731.17 $ 731.17 90 10% 69% 21% 0 2 0 0 0 0 R

26460 $ 715.36 $ 715.36 90 10% 69% 21% 0 2 0 1 0 0 R

26471 $ 1,115.10 $ 1,115.10 90 10% 69% 21% 0 2 0 0 0 0 R

26474 $ 1,086.64 $ 1,086.64 90 10% 69% 21% 0 2 0 2 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


26476 $ 1,050.58 $ 1,050.58 90 10% 69% 21% 0 2 0 1 0 0 R

26477 $ 1,056.28 $ 1,056.28 90 10% 69% 21% 0 2 0 1 1 0 R

26478 $ 1,122.69 $ 1,122.69 90 10% 69% 21% 0 2 0 0 0 0 R

26479 $ 1,115.10 $ 1,115.10 90 10% 69% 21% 0 2 0 2 0 0 R

26480 $ 1,365.57 $ 1,365.57 90 10% 69% 21% 0 2 0 0 0 0 R

26483 $ 1,522.43 $ 1,522.43 90 10% 69% 21% 0 2 0 2 1 0 R

26485 $ 1,461.08 $ 1,461.08 90 10% 69% 21% 0 2 0 2 1 0 R

26489 $ 1,684.35 $ 1,684.35 90 10% 69% 21% 0 2 0 0 0 0 R

26490 $ 1,437.04 $ 1,437.04 90 10% 69% 21% 0 2 0 0 0 0 R

26492 $ 1,592.00 $ 1,592.00 90 10% 69% 21% 0 2 0 2 1 0 R

26494 $ 1,413.01 $ 1,413.01 90 10% 69% 21% 0 2 0 2 1 0 R

26496 $ 1,552.16 $ 1,552.16 90 10% 69% 21% 0 2 0 0 0 0 R

26497 $ 1,561.01 $ 1,561.01 90 10% 69% 21% 0 2 0 2 0 0 R

26498 $ 2,052.46 $ 2,052.46 90 10% 69% 21% 0 2 0 2 1 0 R

26499 $ 1,485.11 $ 1,485.11 90 10% 69% 21% 0 2 0 2 1 0 R

26500 $ 1,130.28 $ 1,130.28 90 10% 69% 21% 0 2 0 0 0 0 R

26502 $ 1,280.81 $ 1,280.81 90 10% 69% 21% 0 2 0 2 0 0 R

26508 $ 1,142.30 $ 1,142.30 90 10% 69% 21% 0 2 1 0 0 0 R

26510 $ 1,079.05 $ 1,079.05 90 10% 69% 21% 0 2 0 0 0 0 R

26516 $ 1,266.90 $ 1,266.90 90 10% 69% 21% 0 2 1 0 0 0 R

26517 $ 1,407.95 $ 1,407.95 90 10% 69% 21% 0 2 1 2 0 0 R

26518 $ 1,493.97 $ 1,493.97 90 10% 69% 21% 0 2 1 2 1 0 R

26520 $ 1,182.78 $ 1,182.78 90 10% 69% 21% 0 2 0 1 0 0 R

26525 $ 1,183.41 $ 1,183.41 90 10% 69% 21% 0 2 0 1 1 0 R

26530 $ 978.48 $ 978.48 90 10% 69% 21% 0 2 0 2 0 0 R

26531 $ 1,134.71 $ 1,134.71 90 10% 69% 21% 0 2 0 2 1 0 R

26535 $ 770.39 $ 770.39 90 10% 69% 21% 0 2 0 1 0 0 R

26536 $ 1,285.87 $ 1,285.87 90 10% 69% 21% 0 2 0 0 0 0 R

26540 $ 1,189.73 $ 1,189.73 90 10% 69% 21% 0 2 0 0 1 0 R

26541 $ 1,445.90 $ 1,445.90 90 10% 69% 21% 0 2 0 2 1 0 R

26542 $ 1,227.68 $ 1,227.68 90 10% 69% 21% 0 2 0 0 0 0 R

26545 $ 1,274.49 $ 1,274.49 90 10% 69% 21% 0 2 0 0 0 0 R

26546 $ 1,799.46 $ 1,799.46 90 10% 69% 21% 0 2 1 2 0 0 R

26548 $ 1,370.00 $ 1,370.00 90 10% 69% 21% 0 2 0 0 0 0 R

26550 $ 2,965.79 $ 2,965.79 90 10% 69% 21% 0 2 1 2 0 0 R

26551 $ 6,056.82 $ 6,056.82 90 10% 69% 21% 0 2 1 2 0 0 R

26553 $ 5,109.34 $ 5,109.34 90 10% 69% 21% 0 2 1 2 1 0 R

26554 $ 5,978.39 $ 5,978.39 90 10% 69% 21% 0 2 1 2 1 0 R

26555 $ 2,312.42 $ 2,312.42 90 10% 69% 21% 0 2 0 2 0 0 R

26556 $ 6,134.62 $ 6,134.62 90 10% 69% 21% 0 2 0 2 1 0 R

26560 $ 1,051.85 $ 1,051.85 90 10% 69% 21% 0 2 0 2 0 0 R

26561 $ 1,679.29 $ 1,679.29 90 10% 69% 21% 0 2 0 2 1 0 R

26562 $ 2,414.25 $ 2,414.25 90 10% 69% 21% 0 2 0 2 0 0 R

26565 $ 1,225.15 $ 1,225.15 90 10% 69% 21% 0 2 0 2 0 0 R

26567 $ 1,227.05 $ 1,227.05 90 10% 69% 21% 0 2 0 0 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


26568 $ 1,625.53 $ 1,625.53 90 10% 69% 21% 0 2 0 2 0 0 R




26591 $ 792.52 $ 792.52 90 10% 69% 21% 0 2 0 0 0 0 R

26593 $ 1,089.80 $ 1,089.80 90 10% 69% 21% 0 2 0 1 0 0 R

26596 $ 1,369.36 $ 1,369.36 90 10% 69% 21% 0 2 0 2 0 0 R

26600 $ 538.89 $ 506.00 90 10% 69% 21% 0 2 0 1 0 0 R

26605 $ 586.96 $ 533.83 90 10% 69% 21% 0 2 0 1 0 0 R

26607 $ 827.31 $ 827.31 90 10% 69% 21% 0 2 0 0 0 0 R

26608 $ 867.16 $ 867.16 90 10% 69% 21% 0 2 0 0 0 0 R

26615 $ 1,048.69 $ 1,048.69 90 10% 69% 21% 0 2 0 1 0 0 R

26641 $ 683.73 $ 621.75 90 10% 69% 21% 0 2 1 0 0 0 R

26645 $ 776.08 $ 710.93 90 10% 69% 21% 0 2 1 0 0 0 R

26650 $ 870.32 $ 870.32 90 10% 69% 21% 0 2 1 1 0 0 R

26665 $ 1,141.66 $ 1,141.66 90 10% 69% 21% 0 2 1 1 1 0 R

26670 $ 617.95 $ 559.76 90 10% 69% 21% 0 2 0 0 0 0 R

26675 $ 821.62 $ 753.31 90 10% 69% 21% 0 2 0 0 0 0 R

26676 $ 910.80 $ 910.80 90 10% 69% 21% 0 2 0 1 0 0 R

26685 $ 1,048.05 $ 1,048.05 90 10% 69% 21% 0 2 0 1 1 0 R

26686 $ 1,130.28 $ 1,130.28 90 10% 69% 21% 0 2 0 2 0 0 R

26700 $ 587.59 $ 550.91 90 10% 69% 21% 0 2 0 1 0 0 R

26705 $ 753.31 $ 688.79 90 10% 69% 21% 0 2 0 0 0 0 R

26706 $ 800.11 $ 800.11 90 10% 69% 21% 0 2 0 1 0 0 R

26715 $ 1,042.36 $ 1,042.36 90 10% 69% 21% 0 2 0 0 0 0 R

26720 $ 363.06 $ 337.12 90 10% 69% 21% 0 2 0 1 0 0 R

26725 $ 612.89 $ 551.54 90 10% 69% 21% 0 2 0 1 0 0 R

26727 $ 855.14 $ 855.14 90 10% 69% 21% 0 2 0 1 0 0 R

26735 $ 1,086.00 $ 1,086.00 90 10% 69% 21% 0 2 0 1 0 0 R

26740 $ 421.88 $ 395.31 90 10% 69% 21% 0 2 0 1 0 0 R

26742 $ 672.35 $ 607.83 90 10% 69% 21% 0 2 0 1 0 0 R

26746 $ 1,349.76 $ 1,349.76 90 10% 69% 21% 0 2 0 1 0 0 R

26750 $ 335.86 $ 337.12 90 10% 69% 21% 0 2 0 1 0 0 R

26755 $ 571.78 $ 495.88 90 10% 69% 21% 0 2 0 1 0 0 R

26756 $ 760.90 $ 760.90 90 10% 69% 21% 0 2 0 0 0 0 R

26765 $ 913.33 $ 913.33 90 10% 69% 21% 0 2 0 1 0 0 R

26770 $ 500.94 $ 462.99 90 10% 69% 21% 0 2 0 1 0 0 R

26775 $ 698.28 $ 630.60 90 10% 69% 21% 0 2 0 1 0 0 R

26776 $ 807.07 $ 807.07 90 10% 69% 21% 0 2 0 1 0 0 R

26785 $ 998.09 $ 998.09 90 10% 69% 21% 0 2 0 1 0 0 R

26820 $ 1,383.28 $ 1,383.28 90 10% 69% 21% 0 2 1 2 1 0 R

26841 $ 1,312.44 $ 1,312.44 90 10% 69% 21% 0 2 1 0 1 0 R

26842 $ 1,414.90 $ 1,414.90 90 10% 69% 21% 0 2 1 2 1 0 R

26843 $ 1,328.88 $ 1,328.88 90 10% 69% 21% 0 2 0 2 1 0 R

26844 $ 1,478.15 $ 1,478.15 90 10% 69% 21% 0 2 0 2 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


26850 $ 1,251.09 $ 1,251.09 90 10% 69% 21% 0 2 0 0 0 0 R

26852 $ 1,437.04 $ 1,437.04 90 10% 69% 21% 0 2 0 2 1 0 R

26860 $ 1,025.92 $ 1,025.92 90 10% 69% 21% 0 2 0 1 0 0 R

26861 $ 187.22 $ 187.22 0 0% 0% 0% 0 0 0 1 0 0 R

26862 $ 1,313.07 $ 1,313.07 90 10% 69% 21% 0 2 0 2 1 0 R

26863 $ 419.35 $ 419.35 0 0% 0% 0% 0 0 0 2 0 0 R

26910 $ 1,301.69 $ 1,301.69 90 10% 69% 21% 0 2 0 1 0 0 R

26951 $ 1,182.78 $ 1,182.78 90 10% 69% 21% 0 2 0 1 0 0 R

26952 $ 1,165.70 $ 1,165.70 90 10% 69% 21% 0 2 0 1 0 0 R


26990 $ 1,137.87 $ 1,137.87 90 10% 69% 21% 0 2 0 1 0 0 R

26991 $ 1,294.10 $ 950.02 90 10% 69% 21% 0 2 0 0 0 0 R

26992 $ 1,740.64 $ 1,740.64 90 10% 69% 21% 0 2 0 0 0 0 R

27000 $ 742.56 $ 742.56 90 10% 69% 21% 0 2 1 1 1 0 R

27001 $ 984.17 $ 984.17 90 10% 69% 21% 0 2 1 2 1 0 R

27003 $ 1,061.97 $ 1,061.97 90 10% 69% 21% 0 2 1 2 1 0 R

27005 $ 1,312.44 $ 1,312.44 90 10% 69% 21% 0 2 1 2 1 0 R

27006 $ 1,333.94 $ 1,333.94 90 10% 69% 21% 0 2 1 2 1 0 R

27025 $ 1,655.25 $ 1,655.25 90 10% 69% 21% 0 2 1 0 1 0 R

27027 $ 1,607.18 $ 1,607.18 90 10% 69% 21% 0 2 1 0 0 0 R

27030 $ 1,695.10 $ 1,695.10 90 10% 69% 21% 0 2 1 2 1 0 R

27033 $ 1,762.15 $ 1,762.15 90 10% 69% 21% 0 2 1 2 1 0 R

27035 $ 1,949.37 $ 1,949.37 90 10% 69% 21% 0 2 1 2 1 0 R Y

27036 $ 1,832.99 $ 1,832.99 90 10% 69% 21% 0 2 1 2 1 0 R

27040 $ 635.66 $ 363.69 10 10% 80% 10% 0 2 1 1 0 0 R

27041 $ 1,254.25 $ 1,254.25 90 10% 69% 21% 0 2 1 1 0 0 R

27043 $ 848.18 $ 848.18 90 10% 69% 21% 0 2 1 1 0 0 R

27045 $ 1,351.65 $ 1,351.65 90 10% 69% 21% 0 2 1 2 1 0 R

27047 $ 851.35 $ 655.90 90 10% 69% 21% 0 2 1 1 0 0 R

27048 $ 1,103.71 $ 1,103.71 90 10% 69% 21% 0 2 1 2 1 0 R


27050 $ 703.97 $ 703.97 90 10% 69% 21% 0 2 1 0 1 0 R

27052 $ 1,054.38 $ 1,054.38 90 10% 69% 21% 0 2 1 2 1 0 R

27054 $ 1,242.23 $ 1,242.23 90 10% 69% 21% 0 2 1 2 1 0 R

27057 $ 1,827.29 $ 1,827.29 90 10% 69% 21% 0 2 1 0 0 0 R


27060 $ 841.23 $ 841.23 90 10% 69% 21% 0 2 1 1 0 0 R

27062 $ 828.58 $ 828.58 90 10% 69% 21% 0 2 1 1 1 0 R

27065 $ 938.63 $ 938.63 90 10% 69% 21% 0 2 1 2 1 0 R

27066 $ 1,475.62 $ 1,475.62 90 10% 69% 21% 0 2 1 2 1 0 R

27067 $ 1,857.02 $ 1,857.02 90 10% 69% 21% 0 2 1 2 0 0 R

27070 $ 1,548.36 $ 1,548.36 90 10% 69% 21% 0 2 1 2 1 0 R

27071 $ 1,662.21 $ 1,662.21 90 10% 69% 21% 0 2 1 2 1 0 R

27075 $ 3,771.60 $ 3,771.60 90 10% 69% 21% 0 2 0 2 1 0 R

27076 $ 4,564.75 $ 4,564.75 90 10% 69% 21% 0 2 0 2 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


27077 $ 5,100.48 $ 5,100.48 90 10% 69% 21% 0 2 0 2 1 0 R

27078 $ 3,726.06 $ 3,726.06 90 10% 69% 21% 0 2 1 2 1 0 R

27080 $ 924.72 $ 924.72 90 10% 69% 21% 0 2 0 2 1 0 R

27086 $ 513.59 $ 293.48 10 10% 80% 10% 0 2 1 0 0 0 R

27087 $ 1,118.89 $ 1,118.89 90 10% 69% 21% 0 2 1 2 1 0 R

27090 $ 1,503.45 $ 1,503.45 90 10% 69% 21% 0 2 1 2 1 0 R

27091 $ 2,890.53 $ 2,890.53 90 10% 69% 21% 0 2 1 2 1 0 R

27093 $ 347.88 $ 127.77 0 0% 0% 0% 0 2 1 1 0 0 R

27095 $ 451.61 $ 151.17 0 0% 0% 0% 0 2 1 1 0 0 R

27096 $ 294.11 $ 153.07 0 0% 0% 0% 0 2 1 1 0 0 R Y-UR

27097 $ 1,227.68 $ 1,227.68 90 10% 69% 21% 0 2 1 2 0 0 R

27098 $ 1,167.60 $ 1,167.60 90 10% 69% 21% 0 2 1 2 0 0 R

27100 $ 1,483.85 $ 1,483.85 90 10% 69% 21% 0 2 1 2 1 0 R

27105 $ 1,571.13 $ 1,571.13 90 10% 69% 21% 0 2 1 2 0 0 R

27110 $ 1,755.19 $ 1,755.19 90 10% 69% 21% 0 2 1 2 1 0 R

27111 $ 1,632.48 $ 1,632.48 90 10% 69% 21% 0 2 1 2 1 0 R

27120 $ 2,345.31 $ 2,345.31 90 10% 69% 21% 0 2 1 2 1 0 R

27122 $ 1,994.27 $ 1,994.27 90 10% 69% 21% 0 2 1 2 1 0 R

27125 $ 2,054.36 $ 2,054.36 90 10% 69% 21% 0 2 1 2 1 0 R

27130 $ 2,456.00 $ 2,456.00 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27132 $ 3,033.47 $ 3,033.47 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27134 $ 3,467.37 $ 3,467.37 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27137 $ 2,667.89 $ 2,667.89 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27138 $ 2,770.35 $ 2,770.35 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27140 $ 1,618.57 $ 1,618.57 90 10% 69% 21% 0 2 1 2 1 0 R

27146 $ 2,309.26 $ 2,309.26 90 10% 69% 21% 0 2 1 2 1 0 R

27147 $ 2,647.65 $ 2,647.65 90 10% 69% 21% 0 2 1 2 1 0 R

27151 $ 2,882.30 $ 2,882.30 90 10% 69% 21% 0 2 1 2 1 0 R

27156 $ 3,075.85 $ 3,075.85 90 10% 69% 21% 0 2 1 2 1 0 R

27158 $ 2,538.86 $ 2,538.86 90 10% 69% 21% 0 2 2 2 0 0 R

27161 $ 2,201.10 $ 2,201.10 90 10% 69% 21% 0 2 1 2 1 0 R

27165 $ 2,488.89 $ 2,488.89 90 10% 69% 21% 0 2 1 2 1 0 R

27170 $ 2,129.63 $ 2,129.63 90 10% 69% 21% 0 2 1 2 1 0 R

27175 $ 1,194.16 $ 1,194.16 90 10% 69% 21% 0 2 1 0 0 0 R

27176 $ 1,665.37 $ 1,665.37 90 10% 69% 21% 0 2 1 2 1 0 R

27177 $ 2,019.57 $ 2,019.57 90 10% 69% 21% 0 2 1 2 1 0 R

27178 $ 1,473.09 $ 1,473.09 90 10% 69% 21% 0 2 1 2 1 0 R

27179 $ 1,732.42 $ 1,732.42 90 10% 69% 21% 0 2 1 2 0 0 R

27181 $ 2,257.39 $ 2,257.39 90 10% 69% 21% 0 2 1 2 0 0 R

27185 $ 1,301.69 $ 1,301.69 90 10% 69% 21% 0 2 1 1 1 0 R

27187 $ 1,797.57 $ 1,797.57 90 10% 69% 21% 0 2 1 2 1 0 R

27197 $ 214.42 $ 214.42 0 0% 0% 0% 0 2 0 1 0 0 R

27198 $ 538.89 $ 538.89 0 0% 0% 0% 0 2 0 0 2 0 R

27200 $ 331.43 $ 345.35 90 10% 69% 21% 0 2 0 1 0 0 R

27202 $ 996.82 $ 996.82 90 10% 69% 21% 0 2 0 2 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


27215 $ 1,133.44 $ 1,133.44 90 10% 69% 21% 9 9 9 9 9 9 R

27216 $ 1,679.29 $ 1,679.29 90 10% 69% 21% 9 9 9 9 9 9 R

27217 $ 1,576.19 $ 1,576.19 90 10% 69% 21% 9 9 9 9 9 9 R

27218 $ 2,174.54 $ 2,174.54 90 10% 69% 21% 9 9 9 9 9 9 R

27220 $ 962.67 $ 954.44 90 10% 69% 21% 0 2 1 1 0 0 R

27222 $ 1,765.31 $ 1,765.31 90 10% 69% 21% 0 2 1 1 0 0 R

27226 $ 1,915.21 $ 1,915.21 90 10% 69% 21% 0 2 1 2 2 0 R

27227 $ 3,006.91 $ 3,006.91 90 10% 69% 21% 0 2 1 2 2 0 R

27228 $ 3,414.24 $ 3,414.24 90 10% 69% 21% 0 2 1 2 2 0 R

27230 $ 864.63 $ 858.30 90 10% 69% 21% 0 2 1 1 0 0 R

27232 $ 1,352.92 $ 1,352.92 90 10% 69% 21% 0 2 1 1 0 0 R

27235 $ 1,648.30 $ 1,648.30 90 10% 69% 21% 0 2 1 1 1 0 R

27236 $ 2,168.84 $ 2,168.84 90 10% 69% 21% 0 2 1 2 1 0 R

27238 $ 837.43 $ 837.43 90 10% 69% 21% 0 2 1 1 0 0 R

27240 $ 1,734.95 $ 1,734.95 90 10% 69% 21% 0 2 1 1 0 0 R

27244 $ 2,231.46 $ 2,231.46 90 10% 69% 21% 0 2 1 2 1 0 R

27245 $ 2,231.46 $ 2,231.46 90 10% 69% 21% 0 2 1 2 2 0 R

27246 $ 698.91 $ 702.71 90 10% 69% 21% 0 2 1 1 0 0 R

27248 $ 1,345.33 $ 1,345.33 90 10% 69% 21% 0 2 1 2 1 0 R

27250 $ 321.31 $ 321.31 0 0% 0% 0% 0 2 1 1 0 0 R

27252 $ 1,371.26 $ 1,371.26 90 10% 69% 21% 0 2 1 1 0 0 R

27253 $ 1,707.12 $ 1,707.12 90 10% 69% 21% 0 2 1 2 1 0 R

27254 $ 2,295.34 $ 2,295.34 90 10% 69% 21% 0 2 1 2 1 0 R

27256 $ 540.79 $ 420.61 10 10% 80% 10% 0 2 1 0 0 0 R

27257 $ 616.69 $ 616.69 10 10% 80% 10% 0 2 1 0 0 0 R

27258 $ 2,008.19 $ 2,008.19 90 10% 69% 21% 0 2 1 2 1 0 R

27259 $ 2,813.36 $ 2,813.36 90 10% 69% 21% 0 2 1 2 0 0 R

27265 $ 724.85 $ 724.85 90 10% 69% 21% 0 2 1 1 0 0 R

27266 $ 1,053.75 $ 1,053.75 90 10% 69% 21% 0 2 1 1 0 0 R

27267 $ 787.46 $ 787.46 90 10% 69% 21% 0 2 1 2 1 0 R

27268 $ 964.56 $ 964.56 90 10% 69% 21% 0 2 1 2 1 0 R

27269 $ 2,249.80 $ 2,249.80 90 10% 69% 21% 0 2 1 2 1 0 R

27275 $ 331.43 $ 331.43 10 10% 80% 10% 0 2 0 1 0 0 R

27279 $1,246.03 $ 1,246.03 90 10% 69% 21% 0 2 1 2 1 0 F Y-UR

27280 $ 2,444.61 $ 2,444.61 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27282 $ 1,475.62 $ 1,475.62 90 10% 69% 21% 0 2 0 2 1 0 R

27284 $ 2,707.73 $ 2,707.73 90 10% 69% 21% 0 2 1 2 1 0 R

27286 $ 2,952.51 $ 2,952.51 90 10% 69% 21% 0 2 1 2 1 0 R

27290 $ 2,908.24 $ 2,908.24 90 10% 69% 21% 0 2 0 2 1 0 R

27295 $ 2,283.96 $ 2,283.96 90 10% 69% 21% 0 2 1 2 1 0 R


27301 $ 1,227.68 $ 908.90 90 10% 69% 21% 0 2 1 1 0 0 R

27303 $ 1,161.90 $ 1,161.90 90 10% 69% 21% 0 2 1 2 1 0 R

27305 $ 872.85 $ 872.85 90 10% 69% 21% 0 2 1 2 1 0 R

27306 $ 643.25 $ 643.25 90 10% 69% 21% 0 2 1 2 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


27307 $ 774.81 $ 774.81 90 10% 69% 21% 0 2 1 0 1 0 R

27310 $ 1,325.09 $ 1,325.09 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27323 $ 499.04 $ 325.74 10 10% 80% 10% 0 2 1 1 0 0 R

27324 $ 721.05 $ 721.05 90 10% 69% 21% 0 2 1 1 0 0 R

27325 $ 918.39 $ 918.39 90 10% 69% 21% 0 2 1 2 0 0 R Y

27326 $ 902.58 $ 902.58 90 10% 69% 21% 0 2 1 2 1 0 R Y

27327 $ 842.49 $ 570.52 90 10% 69% 21% 0 2 1 1 0 0 R

27328 $ 1,123.32 $ 1,123.32 90 10% 69% 21% 0 2 1 1 0 0 R

27329 $ 1,875.36 $ 1,875.36 90 10% 69% 21% 0 2 1 2 1 0 R

27330 $ 748.88 $ 748.88 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR

27331 $ 862.73 $ 862.73 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27332 $ 1,163.80 $ 1,163.80 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27333 $ 1,064.50 $ 1,064.50 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27334 $ 1,240.33 $ 1,240.33 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27335 $ 1,382.65 $ 1,382.65 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27337 $ 754.57 $ 754.57 90 10% 69% 21% 0 2 1 2 0 0 R

27339 $ 1,360.51 $ 1,360.51 90 10% 69% 21% 0 2 1 2 0 0 R

27340 $ 676.78 $ 676.78 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR

27345 $ 871.59 $ 871.59 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27347 $ 960.77 $ 960.77 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27350 $ 1,181.51 $ 1,181.51 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27355 $ 1,094.23 $ 1,094.23 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27356 $ 1,333.31 $ 1,333.31 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27357 $ 1,475.62 $ 1,475.62 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27358 $ 503.47 $ 503.47 0 0% 0% 0% 0 0 0 2 0 0 R Y-UR

27360 $ 1,542.67 $ 1,542.67 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR


27365 $ 3,731.75 $ 3,731.75 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27370 $ 285.89 $ 92.35 0 0% 0% 0% 0 2 1 1 0 0 R

27372 $ 1,108.77 $ 730.54 90 10% 69% 21% 0 2 1 0 0 0 R

27380 $ 1,078.41 $ 1,078.41 90 10% 69% 21% 0 2 1 2 1 0 R

27381 $ 1,449.06 $ 1,449.06 90 10% 69% 21% 0 2 1 2 1 0 R

27385 $ 1,045.52 $ 1,045.52 90 10% 69% 21% 0 2 1 2 1 0 R

27386 $ 1,502.82 $ 1,502.82 90 10% 69% 21% 0 2 1 2 1 0 R

27390 $ 801.38 $ 801.38 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

27391 $ 1,040.46 $ 1,040.46 90 10% 69% 21% 0 2 0 0 1 0 R Y-UR

27392 $ 1,269.43 $ 1,269.43 90 10% 69% 21% 0 2 2 2 1 0 R Y-UR

27393 $ 925.98 $ 925.98 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27394 $ 1,161.90 $ 1,161.90 90 10% 69% 21% 0 2 0 2 0 0 R Y-UR

27395 $ 1,592.64 $ 1,592.64 90 10% 69% 21% 0 2 2 2 1 0 R Y-UR

27396 $ 1,110.67 $ 1,110.67 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27397 $ 1,640.71 $ 1,640.71 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR

27400 $ 1,239.07 $ 1,239.07 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27403 $ 1,160.64 $ 1,160.64 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27405 $ 1,223.26 $ 1,223.26 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


27407 $ 1,404.78 $ 1,404.78 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27409 $ 1,748.86 $ 1,748.86 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27412 $ 2,994.26 $ 2,994.26 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27415 $ 2,491.42 $ 2,491.42 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27416 $ 1,776.69 $ 1,776.69 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR

27418 $ 1,494.60 $ 1,494.60 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27420 $ 1,346.59 $ 1,346.59 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27422 $ 1,347.23 $ 1,347.23 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27424 $ 1,356.71 $ 1,356.71 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27425 $ 814.66 $ 814.66 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR

27427 $ 1,290.30 $ 1,290.30 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27428 $ 2,017.68 $ 2,017.68 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27429 $ 2,255.50 $ 2,255.50 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27430 $ 1,340.27 $ 1,340.27 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27435 $ 1,464.24 $ 1,464.24 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27437 $ 1,199.85 $ 1,199.85 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR

27438 $ 1,522.43 $ 1,522.43 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27440 $ 1,442.73 $ 1,442.73 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27441 $ 1,495.23 $ 1,495.23 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27442 $ 1,576.82 $ 1,576.82 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27443 $ 1,473.73 $ 1,473.73 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27445 $ 2,269.41 $ 2,269.41 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27446 $ 2,099.90 $ 2,099.90 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27447 $ 2,454.73 $ 2,454.73 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27448 $ 1,398.46 $ 1,398.46 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27450 $ 1,836.15 $ 1,836.15 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27454 $ 2,351.00 $ 2,351.00 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27455 $ 1,705.22 $ 1,705.22 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27457 $ 1,714.08 $ 1,714.08 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27465 $ 2,232.09 $ 2,232.09 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27466 $ 2,129.00 $ 2,129.00 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27468 $ 2,431.96 $ 2,431.96 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27470 $ 2,130.26 $ 2,130.26 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27472 $ 2,287.12 $ 2,287.12 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR





27486 $ 2,549.61 $ 2,549.61 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27487 $ 3,184.01 $ 3,184.01 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27488 $ 2,176.43 $ 2,176.43 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27495 $ 2,038.55 $ 2,038.55 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27496 $ 975.95 $ 975.95 90 10% 69% 21% 0 2 1 1 0 0 R

27497 $ 1,046.79 $ 1,046.79 90 10% 69% 21% 0 2 1 0 2 0 R

27498 $ 1,179.61 $ 1,179.61 90 10% 69% 21% 0 2 1 2 2 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


27499 $ 1,258.68 $ 1,258.68 90 10% 69% 21% 0 2 1 2 2 0 R

27500 $ 943.69 $ 870.95 90 10% 69% 21% 0 2 1 1 0 0 R

27501 $ 913.96 $ 905.74 90 10% 69% 21% 0 2 1 0 0 0 R

27502 $ 1,375.69 $ 1,375.69 90 10% 69% 21% 0 2 1 1 0 0 R

27503 $ 1,449.06 $ 1,449.06 90 10% 69% 21% 0 2 1 0 0 0 R

27506 $ 2,425.01 $ 2,425.01 90 10% 69% 21% 0 2 1 2 1 0 R

27507 $ 1,761.51 $ 1,761.51 90 10% 69% 21% 0 2 1 2 2 0 R

27508 $ 955.71 $ 896.89 90 10% 69% 21% 0 2 1 1 0 0 R

27509 $ 1,168.23 $ 1,168.23 90 10% 69% 21% 0 2 1 0 0 0 R

27510 $ 1,235.27 $ 1,235.27 90 10% 69% 21% 0 2 1 1 0 0 R

27511 $ 1,804.52 $ 1,804.52 90 10% 69% 21% 0 2 1 2 2 0 R

27513 $ 2,242.21 $ 2,242.21 90 10% 69% 21% 0 2 1 2 2 0 R

27514 $ 1,749.50 $ 1,749.50 90 10% 69% 21% 0 2 1 2 1 0 R

27516 $ 923.45 $ 864.63 90 10% 69% 21% 0 2 1 1 0 0 R

27517 $ 1,165.07 $ 1,165.07 90 10% 69% 21% 0 2 1 0 0 0 R

27519 $ 1,614.14 $ 1,614.14 90 10% 69% 21% 0 2 1 2 1 0 R

27520 $ 591.39 $ 538.26 90 10% 69% 21% 0 2 1 1 0 0 R

27524 $ 1,364.30 $ 1,364.30 90 10% 69% 21% 0 2 1 2 1 0 R

27530 $ 553.44 $ 512.96 90 10% 69% 21% 0 2 1 1 0 0 R

27532 $ 1,117.63 $ 1,046.79 90 10% 69% 21% 0 2 1 1 0 0 R

27535 $ 1,624.26 $ 1,624.26 90 10% 69% 21% 0 2 1 2 2 0 R

27536 $ 2,155.56 $ 2,155.56 90 10% 69% 21% 0 2 1 2 1 0 R

27538 $ 868.42 $ 812.13 90 10% 69% 21% 0 2 1 0 0 0 R

27540 $ 1,472.46 $ 1,472.46 90 10% 69% 21% 0 2 1 2 1 0 R

27550 $ 923.45 $ 854.51 90 10% 69% 21% 0 2 1 0 0 0 R

27552 $ 1,138.50 $ 1,138.50 90 10% 69% 21% 0 2 1 0 0 0 R

27556 $ 1,564.17 $ 1,564.17 90 10% 69% 21% 0 2 1 2 1 0 R

27557 $ 1,849.43 $ 1,849.43 90 10% 69% 21% 0 2 1 2 1 0 R

27558 $ 2,162.52 $ 2,162.52 90 10% 69% 21% 0 2 1 2 2 0 R

27560 $ 655.90 $ 604.04 90 10% 69% 21% 0 2 1 1 0 0 R

27562 $ 864.00 $ 864.00 90 10% 69% 21% 0 2 1 0 0 0 R

27566 $ 1,612.24 $ 1,612.24 90 10% 69% 21% 0 2 1 2 1 0 R

27570 $ 275.14 $ 275.14 10 10% 80% 10% 0 2 1 1 0 0 R

27580 $ 2,603.37 $ 2,603.37 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27590 $ 1,439.57 $ 1,439.57 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27591 $ 1,750.13 $ 1,750.13 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27592 $ 1,232.11 $ 1,232.11 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

27594 $ 913.96 $ 913.96 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR

27596 $ 1,303.58 $ 1,303.58 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR

27598 $ 1,293.46 $ 1,293.46 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR


27600 $ 737.50 $ 737.50 90 10% 69% 21% 0 2 1 1 1 0 R

27601 $ 810.87 $ 810.87 90 10% 69% 21% 0 2 1 1 0 0 R

27602 $ 878.54 $ 878.54 90 10% 69% 21% 0 2 1 2 1 0 R

27603 $ 968.36 $ 703.97 90 10% 69% 21% 0 2 1 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


27604 $ 903.84 $ 626.81 90 10% 69% 21% 0 2 1 0 0 0 R

27605 $ 637.56 $ 339.65 10 10% 80% 10% 0 2 1 0 0 0 R

27606 $ 512.33 $ 512.33 10 10% 80% 10% 0 2 1 1 1 0 R

27607 $ 1,103.71 $ 1,103.71 90 10% 69% 21% 0 2 1 1 0 0 R

27610 $ 1,180.88 $ 1,180.88 90 10% 69% 21% 0 2 1 1 0 0 R

27612 $ 1,027.81 $ 1,027.81 90 10% 69% 21% 0 2 1 2 1 0 R

27613 $ 467.42 $ 298.54 10 10% 80% 10% 0 2 1 1 0 0 R

27614 $ 1,067.03 $ 740.03 90 10% 69% 21% 0 2 1 1 0 0 R



27618 $ 829.84 $ 562.29 90 10% 69% 21% 0 2 1 1 0 0 R

27619 $ 851.35 $ 851.35 90 10% 69% 21% 0 2 1 1 0 0 R

27620 $ 829.84 $ 829.84 90 10% 69% 21% 0 2 1 2 1 0 R

27625 $ 1,055.64 $ 1,055.64 90 10% 69% 21% 0 2 1 2 1 0 R

27626 $ 1,102.45 $ 1,102.45 90 10% 69% 21% 0 2 1 2 0 0 R

27630 $ 1,034.77 $ 666.02 90 10% 69% 21% 0 2 1 1 0 0 R

27632 $ 748.25 $ 748.25 90 10% 69% 21% 0 2 1 2 0 0 R

27634 $ 1,240.33 $ 1,240.33 90 10% 69% 21% 0 2 1 2 0 0 R

27635 $ 1,064.50 $ 1,064.50 90 10% 69% 21% 0 2 1 1 1 0 R

27637 $ 1,382.65 $ 1,382.65 90 10% 69% 21% 0 2 1 2 1 0 R

27638 $ 1,383.91 $ 1,383.91 90 10% 69% 21% 0 2 1 2 1 0 R

27640 $ 1,513.57 $ 1,513.57 90 10% 69% 21% 0 2 1 1 1 0 R

27641 $ 1,213.77 $ 1,213.77 90 10% 69% 21% 0 2 1 1 1 0 R

27645 $ 3,211.84 $ 3,211.84 90 10% 69% 21% 0 2 1 2 1 0 R

27646 $ 2,688.76 $ 2,688.76 90 10% 69% 21% 0 2 1 2 1 0 R

27647 $ 1,876.63 $ 1,876.63 90 10% 69% 21% 0 2 1 2 0 0 R

27648 $ 308.03 $ 95.51 0 0% 0% 0% 0 2 1 0 0 0 R

27650 $ 1,201.12 $ 1,201.12 90 10% 69% 21% 0 2 1 2 1 0 R

27652 $ 1,247.92 $ 1,247.92 90 10% 69% 21% 0 2 1 1 1 0 R

27654 $ 1,292.20 $ 1,292.20 90 10% 69% 21% 0 2 1 2 1 0 R

27656 $ 1,147.36 $ 711.56 90 10% 69% 21% 0 2 1 2 0 0 R

27658 $ 681.84 $ 681.84 90 10% 69% 21% 0 2 0 2 1 0 R

27659 $ 873.48 $ 873.48 90 10% 69% 21% 0 2 0 2 1 0 R

27664 $ 663.49 $ 663.49 90 10% 69% 21% 0 2 0 0 0 0 R

27665 $ 750.78 $ 750.78 90 10% 69% 21% 0 2 0 2 1 0 R

27675 $ 894.99 $ 894.99 90 10% 69% 21% 0 2 1 2 1 0 R

27676 $ 1,104.98 $ 1,104.98 90 10% 69% 21% 0 2 1 2 0 0 R

27680 $ 783.67 $ 783.67 90 10% 69% 21% 0 2 0 1 1 0 R

27681 $ 993.66 $ 993.66 90 10% 69% 21% 0 2 1 1 1 0 R

27685 $ 1,228.95 $ 848.82 90 10% 69% 21% 0 2 1 2 1 0 R

27686 $ 1,017.69 $ 1,017.69 90 10% 69% 21% 0 2 1 1 1 0 R

27687 $ 829.21 $ 829.21 90 10% 69% 21% 0 2 1 2 1 0 R

27690 $ 1,158.11 $ 1,158.11 90 10% 69% 21% 0 2 1 2 1 0 R

27691 $ 1,363.04 $ 1,363.04 90 10% 69% 21% 0 2 1 2 1 0 R

27692 $ 189.12 $ 189.12 0 0% 0% 0% 0 0 0 2 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


27695 $ 871.59 $ 871.59 90 10% 69% 21% 0 2 1 1 1 0 R

27696 $ 1,008.84 $ 1,008.84 90 10% 69% 21% 0 2 1 1 1 0 R

27698 $ 1,166.96 $ 1,166.96 90 10% 69% 21% 0 2 1 2 1 0 R

27700 $ 1,111.30 $ 1,111.30 90 10% 69% 21% 0 2 1 2 1 0 R

27702 $ 1,748.86 $ 1,748.86 90 10% 69% 21% 0 2 1 2 1 0 R

27703 $ 2,011.98 $ 2,011.98 90 10% 69% 21% 0 2 1 2 0 0 R

27704 $ 1,046.16 $ 1,046.16 90 10% 69% 21% 0 2 1 1 1 0 R

27705 $ 1,375.69 $ 1,375.69 90 10% 69% 21% 0 2 1 2 1 0 R

27707 $ 730.54 $ 730.54 90 10% 69% 21% 0 2 1 1 1 0 R

27709 $ 2,122.67 $ 2,122.67 90 10% 69% 21% 0 2 1 2 1 0 R

27712 $ 2,005.03 $ 2,005.03 90 10% 69% 21% 0 2 1 2 1 0 R

27715 $ 1,901.93 $ 1,901.93 90 10% 69% 21% 0 2 1 2 1 0 R

27720 $ 1,586.31 $ 1,586.31 90 10% 69% 21% 0 2 1 2 1 0 R

27722 $ 1,615.41 $ 1,615.41 90 10% 69% 21% 0 2 1 2 1 0 R

27724 $ 2,287.12 $ 2,287.12 90 10% 69% 21% 0 2 1 2 1 0 R

27725 $ 2,158.72 $ 2,158.72 90 10% 69% 21% 0 2 1 2 1 0 R

27726 $ 1,743.80 $ 1,743.80 90 10% 69% 21% 0 2 1 1 1 0 R


27730 $ 1,007.57 $ 1,007.57 90 10% 69% 21% 0 2 1 1 1 0 R Y

27732 $ 676.78 $ 676.78 90 10% 69% 21% 0 2 1 1 0 0 R Y

27734 $ 1,189.73 $ 1,189.73 90 10% 69% 21% 0 2 1 1 0 0 R Y

27740 $ 1,265.63 $ 1,265.63 90 10% 69% 21% 0 2 1 2 0 0 R Y

27742 $ 1,382.01 $ 1,382.01 90 10% 69% 21% 0 2 1 2 1 0 R Y

27745 $ 1,371.89 $ 1,371.89 90 10% 69% 21% 0 2 1 2 1 0 R

27750 $ 633.77 $ 580.00 90 10% 69% 21% 0 2 1 1 0 0 R

27752 $ 975.95 $ 898.15 90 10% 69% 21% 0 2 1 1 0 0 R

27756 $ 1,048.69 $ 1,048.69 90 10% 69% 21% 0 2 1 2 1 0 R

27758 $ 1,616.04 $ 1,616.04 90 10% 69% 21% 0 2 1 2 1 0 R

27759 $ 1,809.58 $ 1,809.58 90 10% 69% 21% 0 2 1 2 2 0 R

27760 $ 609.73 $ 555.34 90 10% 69% 21% 0 2 1 1 0 0 R

27762 $ 857.67 $ 778.61 90 10% 69% 21% 0 2 1 1 0 0 R

27766 $ 1,108.14 $ 1,108.14 90 10% 69% 21% 0 2 1 1 1 0 R

27767 $ 513.59 $ 516.75 90 10% 69% 21% 0 2 1 1 0 0 R

27768 $ 797.58 $ 797.58 90 10% 69% 21% 0 2 1 1 0 0 R

27769 $ 1,310.54 $ 1,310.54 90 10% 69% 21% 0 2 1 1 0 0 R

27780 $ 561.03 $ 509.80 90 10% 69% 21% 0 2 1 1 0 0 R

27781 $ 777.98 $ 719.79 90 10% 69% 21% 0 2 1 1 0 0 R

27784 $ 1,298.52 $ 1,298.52 90 10% 69% 21% 0 2 1 1 1 0 R

27786 $ 578.74 $ 523.08 90 10% 69% 21% 0 2 1 1 0 0 R

27788 $ 767.22 $ 698.91 90 10% 69% 21% 0 2 1 1 0 0 R

27792 $ 1,185.94 $ 1,185.94 90 10% 69% 21% 0 2 1 1 1 0 R

27808 $ 612.89 $ 549.01 90 10% 69% 21% 0 2 1 1 0 0 R

27810 $ 848.82 $ 767.86 90 10% 69% 21% 0 2 1 1 0 0 R

27814 $ 1,400.99 $ 1,400.99 90 10% 69% 21% 0 2 1 2 1 0 R

27816 $ 589.49 $ 527.51 90 10% 69% 21% 0 2 1 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


27818 $ 880.44 $ 786.20 90 10% 69% 21% 0 2 1 1 0 0 R

27822 $ 1,563.54 $ 1,563.54 90 10% 69% 21% 0 2 1 2 1 0 R

27823 $ 1,769.74 $ 1,769.74 90 10% 69% 21% 0 2 1 2 1 0 R

27824 $ 573.05 $ 556.60 90 10% 69% 21% 0 2 1 1 0 0 R

27825 $ 989.23 $ 894.36 90 10% 69% 21% 0 2 1 0 0 0 R

27826 $ 1,548.99 $ 1,548.99 90 10% 69% 21% 0 2 1 2 2 0 R

27827 $ 1,999.33 $ 1,999.33 90 10% 69% 21% 0 2 1 2 2 0 R

27828 $ 2,385.79 $ 2,385.79 90 10% 69% 21% 0 2 1 2 2 0 R

27829 $ 1,268.80 $ 1,268.80 90 10% 69% 21% 0 2 1 2 2 0 R

27830 $ 686.90 $ 638.83 90 10% 69% 21% 0 2 1 0 0 0 R

27831 $ 690.06 $ 690.06 90 10% 69% 21% 0 2 1 0 0 0 R

27832 $ 1,373.79 $ 1,373.79 90 10% 69% 21% 0 2 1 2 1 0 R

27840 $ 669.19 $ 669.19 90 10% 69% 21% 0 2 1 1 0 0 R

27842 $ 895.62 $ 895.62 90 10% 69% 21% 0 2 1 1 0 0 R

27846 $ 1,323.19 $ 1,323.19 90 10% 69% 21% 0 2 1 2 1 0 R

27848 $ 1,463.61 $ 1,463.61 90 10% 69% 21% 0 2 1 2 1 0 R

27860 $ 314.99 $ 314.99 10 10% 80% 10% 0 2 1 0 0 0 R

27870 $ 1,870.30 $ 1,870.30 90 10% 69% 21% 0 2 1 2 1 0 R

27871 $ 1,244.13 $ 1,244.13 90 10% 69% 21% 0 2 1 2 1 0 R

27880 $ 1,651.46 $ 1,651.46 90 10% 69% 21% 0 2 1 2 1 0 R

27881 $ 1,567.97 $ 1,567.97 90 10% 69% 21% 0 2 1 2 1 0 R

27882 $ 1,082.21 $ 1,082.21 90 10% 69% 21% 0 2 1 0 1 0 R

27884 $ 1,041.10 $ 1,041.10 90 10% 69% 21% 0 2 1 1 0 0 R

27886 $ 1,190.37 $ 1,190.37 90 10% 69% 21% 0 2 1 1 1 0 R

27888 $ 1,249.19 $ 1,249.19 90 10% 69% 21% 0 2 1 2 1 0 R

27889 $ 1,166.33 $ 1,166.33 90 10% 69% 21% 0 2 1 1 1 0 R

27892 $ 1,008.84 $ 1,008.84 90 10% 69% 21% 0 2 1 0 0 0 R

27893 $ 1,101.18 $ 1,101.18 90 10% 69% 21% 0 2 1 0 0 0 R

27894 $ 1,550.89 $ 1,550.89 90 10% 69% 21% 0 2 1 2 0 0 R


28001 $ 517.39 $ 311.82 10 10% 80% 10% 0 2 0 1 0 0 R

28002 $ 819.72 $ 582.53 10 10% 80% 10% 0 2 0 1 0 0 R

28003 $ 1,299.16 $ 1,029.08 90 10% 69% 21% 0 2 0 1 0 0 R

28005 $ 1,058.17 $ 1,058.17 90 10% 69% 21% 0 2 0 1 0 0 R

28008 $ 810.23 $ 541.42 90 10% 69% 21% 0 2 1 1 0 0 R

28010 $ 430.10 $ 385.83 90 10% 69% 21% 0 2 0 1 0 0 R

28011 $ 593.29 $ 527.51 90 10% 69% 21% 0 2 0 1 0 0 R

28020 $ 1,008.21 $ 664.13 90 10% 69% 21% 0 2 0 1 1 0 R

28022 $ 908.90 $ 595.82 90 10% 69% 21% 0 2 0 1 0 0 R

28024 $ 860.20 $ 559.76 90 10% 69% 21% 0 2 0 1 0 0 R

28035 $ 986.07 $ 653.37 90 10% 69% 21% 0 2 1 1 1 0 R

28039 $ 945.59 $ 641.36 90 10% 69% 21% 0 2 1 2 0 0 R

28041 $ 838.70 $ 838.70 90 10% 69% 21% 0 2 1 0 0 0 R

28043 $ 752.04 $ 485.76 90 10% 69% 21% 0 2 1 1 0 0 R

28045 $ 929.14 $ 641.99 90 10% 69% 21% 0 2 1 0 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY




28050 $ 889.93 $ 569.88 90 10% 69% 21% 0 2 1 1 1 0 R

28052 $ 831.11 $ 521.81 90 10% 69% 21% 0 2 1 1 1 0 R

28054 $ 724.21 $ 444.65 90 10% 69% 21% 0 2 1 0 0 0 R

28055 $ 693.85 $ 693.85 90 10% 69% 21% 0 2 1 0 0 0 R

28060 $ 967.73 $ 656.54 90 10% 69% 21% 0 2 1 1 0 0 R

28062 $ 1,097.39 $ 750.15 90 10% 69% 21% 0 2 1 1 1 0 R

28070 $ 1,004.41 $ 658.43 90 10% 69% 21% 0 2 0 1 0 0 R

28072 $ 953.81 $ 613.53 90 10% 69% 21% 0 2 0 1 0 0 R

28080 $ 987.33 $ 680.57 90 10% 69% 21% 0 2 0 0 0 0 R

28086 $ 1,020.22 $ 660.96 90 10% 69% 21% 0 2 1 2 1 0 R

28088 $ 838.06 $ 519.92 90 10% 69% 21% 0 2 1 0 0 0 R

28090 $ 881.71 $ 567.99 90 10% 69% 21% 0 2 1 1 0 0 R

28092 $ 798.22 $ 498.41 90 10% 69% 21% 0 2 0 1 0 0 R

28100 $ 1,133.44 $ 757.74 90 10% 69% 21% 0 2 1 2 1 0 R

28102 $ 1,101.18 $ 1,101.18 90 10% 69% 21% 0 2 1 2 0 0 R

28103 $ 730.54 $ 730.54 90 10% 69% 21% 0 2 1 2 0 0 R

28104 $ 987.97 $ 650.21 90 10% 69% 21% 0 2 0 2 1 0 R

28106 $ 789.99 $ 789.99 90 10% 69% 21% 0 2 0 2 1 0 R

28107 $ 969.62 $ 644.52 90 10% 69% 21% 0 2 0 2 0 0 R

28108 $ 826.68 $ 532.57 90 10% 69% 21% 0 2 0 1 0 0 R

28110 $ 871.59 $ 534.46 90 10% 69% 21% 0 2 1 1 1 0 R

28111 $ 921.55 $ 598.35 90 10% 69% 21% 0 2 1 1 1 0 R

28112 $ 918.39 $ 576.84 90 10% 69% 21% 0 2 1 1 1 0 R

28113 $ 1,108.14 $ 785.57 90 10% 69% 21% 0 2 1 0 0 0 R

28114 $ 1,996.80 $ 1,538.24 90 10% 69% 21% 0 2 1 2 1 0 R

28116 $ 1,414.27 $ 1,051.85 90 10% 69% 21% 0 2 1 1 0 0 R

28118 $ 1,104.35 $ 755.21 90 10% 69% 21% 0 2 1 2 1 0 R

28119 $ 983.54 $ 664.76 90 10% 69% 21% 0 2 1 1 1 0 R

28120 $ 1,258.04 $ 911.43 90 10% 69% 21% 0 2 1 1 1 0 R

28122 $ 1,118.26 $ 809.60 90 10% 69% 21% 0 2 1 2 1 0 R

28124 $ 895.62 $ 610.36 90 10% 69% 21% 0 2 1 1 0 0 R

28126 $ 745.09 $ 459.20 90 10% 69% 21% 0 2 0 1 0 0 R

28130 $ 1,175.19 $ 1,175.19 90 10% 69% 21% 0 2 1 2 1 0 R

28140 $ 1,106.24 $ 803.28 90 10% 69% 21% 0 2 0 1 1 0 R

28150 $ 800.11 $ 516.75 90 10% 69% 21% 0 2 0 1 0 0 R

28153 $ 772.92 $ 487.03 90 10% 69% 21% 0 2 0 1 0 0 R

28160 $ 789.36 $ 496.51 90 10% 69% 21% 0 2 0 1 0 0 R




28190 $ 484.50 $ 246.68 10 10% 80% 10% 0 2 1 1 0 0 R

28192 $ 878.54 $ 577.47 90 10% 69% 21% 0 2 1 1 0 0 R

28193 $ 994.29 $ 679.94 90 10% 69% 21% 0 2 1 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


28200 $ 920.92 $ 593.29 90 10% 69% 21% 0 2 0 1 1 0 R

28202 $ 1,108.77 $ 779.87 90 10% 69% 21% 0 2 0 2 1 0 R

28208 $ 894.36 $ 578.11 90 10% 69% 21% 0 2 0 1 1 0 R

28210 $ 1,089.17 $ 762.16 90 10% 69% 21% 0 2 0 2 0 0 R

28220 $ 848.18 $ 559.13 90 10% 69% 21% 0 2 1 1 0 0 R

28222 $ 950.65 $ 643.89 90 10% 69% 21% 0 2 1 1 0 0 R

28225 $ 776.71 $ 481.97 90 10% 69% 21% 0 2 1 1 1 0 R

28226 $ 922.82 $ 586.96 90 10% 69% 21% 0 2 1 1 0 0 R

28230 $ 817.82 $ 523.08 90 10% 69% 21% 0 2 1 1 0 0 R

28232 $ 729.91 $ 449.71 90 10% 69% 21% 0 2 0 1 0 0 R

28234 $ 769.12 $ 488.29 90 10% 69% 21% 0 2 0 1 0 0 R

28238 $ 1,248.56 $ 891.83 90 10% 69% 21% 0 2 1 2 1 0 R

28240 $ 848.18 $ 545.85 90 10% 69% 21% 0 2 1 1 0 0 R

28250 $ 1,078.41 $ 739.39 90 10% 69% 21% 0 2 1 2 1 0 R

28260 $ 1,289.04 $ 943.06 90 10% 69% 21% 0 2 1 2 1 0 R

28261 $ 1,855.12 $ 1,447.16 90 10% 69% 21% 0 2 1 0 0 0 R

28262 $ 2,696.35 $ 2,145.44 90 10% 69% 21% 0 2 1 2 1 0 R

28264 $ 1,620.47 $ 1,228.32 90 10% 69% 21% 0 2 1 2 0 0 R

28270 $ 923.45 $ 616.69 90 10% 69% 21% 0 2 1 1 0 0 R

28272 $ 741.92 $ 469.95 90 10% 69% 21% 0 2 1 1 0 0 R

28280 $ 967.09 $ 642.62 90 10% 69% 21% 0 2 1 0 0 0 R

28285 $ 1,002.51 $ 697.02 90 10% 69% 21% 0 2 1 1 1 0 R

28286 $ 846.29 $ 551.54 90 10% 69% 21% 0 2 1 1 0 0 R

28288 $ 1,130.91 $ 791.89 90 10% 69% 21% 0 2 0 1 0 0 R

28289 $ 1,400.99 $ 854.51 90 10% 69% 21% 0 2 1 2 1 0 R

28291 $ 1,368.73 $ 881.71 090 10% 69% 21% 0 2 1 2 1 0 R Y-UR

28292 $ 1,401.62 $ 891.19 90 10% 69% 21% 0 2 1 2 1 0 R

28295 $ 1,765.31 $ 986.70 090 10% 69% 21% 0 2 1 2 1 0 R Y-UR

28296 $ 1,715.34 $ 948.75 90 10% 69% 21% 0 2 1 2 1 0 R

28297 $ 1,965.81 $ 1,105.61 90 10% 69% 21% 0 2 1 2 1 0 R

28298 $ 1,596.43 $ 910.80 90 10% 69% 21% 0 2 1 2 1 0 R

28299 $ 1,881.69 $ 1,064.50 90 10% 69% 21% 0 2 1 2 1 0 R

28300 $ 1,186.57 $ 1,186.57 90 10% 69% 21% 0 2 1 2 1 0 R

28302 $ 1,299.16 $ 1,299.16 90 10% 69% 21% 0 2 1 2 1 0 R

28304 $ 1,537.61 $ 1,110.67 90 10% 69% 21% 0 2 1 2 1 0 R

28305 $ 1,218.83 $ 1,218.83 90 10% 69% 21% 0 2 1 2 1 0 R

28306 $ 1,149.25 $ 740.66 90 10% 69% 21% 0 2 1 2 1 0 R

28307 $ 1,246.66 $ 808.34 90 10% 69% 21% 0 2 1 0 0 0 R

28308 $ 1,063.87 $ 695.75 90 10% 69% 21% 0 2 1 2 1 0 R

28309 $ 1,640.07 $ 1,640.07 90 10% 69% 21% 0 2 1 0 0 0 R

28310 $ 1,027.18 $ 659.70 90 10% 69% 21% 0 2 1 1 1 0 R

28312 $ 955.71 $ 587.59 90 10% 69% 21% 0 2 0 1 1 0 R

28313 $ 985.44 $ 656.54 90 10% 69% 21% 0 2 0 1 0 0 R

28315 $ 905.11 $ 600.88 90 10% 69% 21% 0 2 1 1 1 0 R

28320 $ 1,117.00 $ 1,117.00 90 10% 69% 21% 0 2 1 2 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


28322 $ 1,460.44 $ 1,053.75 90 10% 69% 21% 0 2 0 2 1 0 R






28400 $ 458.56 $ 418.08 90 10% 69% 21% 0 2 1 1 0 0 R

28405 $ 720.42 $ 651.48 90 10% 69% 21% 0 2 1 0 0 0 R

28406 $ 950.65 $ 950.65 90 10% 69% 21% 0 2 1 0 0 0 R

28415 $ 2,045.51 $ 2,045.51 90 10% 69% 21% 0 2 1 2 1 0 R

28420 $ 2,309.89 $ 2,309.89 90 10% 69% 21% 0 2 1 2 1 0 R

28430 $ 435.79 $ 385.83 90 10% 69% 21% 0 2 1 1 0 0 R

28435 $ 590.76 $ 526.24 90 10% 69% 21% 0 2 1 0 0 0 R

28436 $ 815.29 $ 815.29 90 10% 69% 21% 0 2 1 1 0 0 R

28445 $ 1,932.92 $ 1,932.92 90 10% 69% 21% 0 2 1 2 1 0 R

28446 $ 2,185.29 $ 2,185.29 90 10% 69% 21% 0 2 1 2 1 0 R

28450 $ 399.11 $ 354.20 90 10% 69% 21% 0 2 0 1 0 0 R

28455 $ 530.67 $ 475.64 90 10% 69% 21% 0 2 0 0 0 0 R

28456 $ 580.64 $ 580.64 90 10% 69% 21% 0 2 0 1 0 0 R

28465 $ 1,149.89 $ 1,149.89 90 10% 69% 21% 0 2 0 1 0 0 R

28470 $ 404.17 $ 376.97 90 10% 69% 21% 0 2 0 1 0 0 R

28475 $ 470.58 $ 416.19 90 10% 69% 21% 0 2 0 1 0 0 R

28476 $ 649.58 $ 649.58 90 10% 69% 21% 0 2 0 0 0 0 R

28485 $ 994.92 $ 994.92 90 10% 69% 21% 0 2 0 1 1 0 R

28490 $ 270.71 $ 232.13 90 10% 69% 21% 0 2 1 1 0 0 R

28495 $ 330.80 $ 277.67 90 10% 69% 21% 0 2 1 1 0 0 R

28496 $ 843.12 $ 440.22 90 10% 69% 21% 0 2 1 1 0 0 R

28505 $ 1,244.13 $ 918.39 90 10% 69% 21% 0 2 1 1 0 0 R

28510 $ 229.60 $ 223.27 90 10% 69% 21% 0 2 0 1 0 0 R

28515 $ 300.44 $ 264.39 90 10% 69% 21% 0 2 0 1 0 0 R

28525 $ 1,053.75 $ 729.91 90 10% 69% 21% 0 2 0 0 0 0 R

28530 $ 214.42 $ 189.75 90 10% 69% 21% 0 2 1 0 0 0 R

28531 $ 648.31 $ 337.76 90 10% 69% 21% 0 2 1 1 2 0 R

28540 $ 358.00 $ 323.21 90 10% 69% 21% 0 2 1 0 0 0 R

28545 $ 545.22 $ 481.97 90 10% 69% 21% 0 2 1 0 0 0 R

28546 $ 1,053.75 $ 611.00 90 10% 69% 21% 0 2 1 0 0 0 R

28555 $ 1,625.53 $ 1,217.56 90 10% 69% 21% 0 2 1 2 1 0 R

28570 $ 335.86 $ 283.36 90 10% 69% 21% 0 2 1 0 0 0 R

28575 $ 651.48 $ 587.59 90 10% 69% 21% 0 2 1 0 0 0 R

28576 $ 721.68 $ 721.68 90 10% 69% 21% 0 2 1 0 0 0 R

28585 $ 1,602.76 $ 1,240.33 90 10% 69% 21% 0 2 1 2 1 0 R

28600 $ 410.49 $ 350.41 90 10% 69% 21% 0 2 0 0 0 0 R

28605 $ 603.41 $ 540.16 90 10% 69% 21% 0 2 0 0 0 0 R

28606 $ 724.85 $ 724.85 90 10% 69% 21% 0 2 0 1 0 0 R

28615 $ 1,470.56 $ 1,470.56 90 10% 69% 21% 0 2 0 2 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


28630 $ 293.48 $ 202.40 10 10% 80% 10% 0 2 0 0 0 0 R

28635 $ 326.37 $ 242.88 10 10% 80% 10% 0 2 0 0 0 0 R

28636 $ 649.58 $ 409.23 10 10% 80% 10% 0 2 0 1 2 0 R

28645 $ 1,222.62 $ 889.93 90 10% 69% 21% 0 2 0 1 1 0 R

28660 $ 215.68 $ 163.19 10 10% 80% 10% 0 2 0 1 0 0 R

28665 $ 287.16 $ 242.25 10 10% 80% 10% 0 2 0 0 0 0 R

28666 $ 339.02 $ 339.02 10 10% 80% 10% 0 2 0 1 2 0 R

28675 $ 1,091.70 $ 757.74 90 10% 69% 21% 0 2 0 1 0 0 R

28705 $ 2,266.25 $ 2,266.25 90 10% 69% 21% 0 2 1 2 1 0 R

28715 $ 1,710.91 $ 1,710.91 90 10% 69% 21% 0 2 1 2 1 0 R

28725 $ 1,419.33 $ 1,419.33 90 10% 69% 21% 0 2 1 2 1 0 R

28730 $ 1,337.74 $ 1,337.74 90 10% 69% 21% 0 2 1 2 1 0 R

28735 $ 1,429.45 $ 1,429.45 90 10% 69% 21% 0 2 1 2 1 0 R

28737 $ 1,273.86 $ 1,273.86 90 10% 69% 21% 0 2 1 2 1 0 R

28740 $ 1,572.40 $ 1,140.40 90 10% 69% 21% 0 2 0 2 1 0 R

28750 $ 1,508.51 $ 1,079.68 90 10% 69% 21% 0 2 1 0 0 0 R

28755 $ 953.18 $ 608.47 90 10% 69% 21% 0 2 1 1 1 0 R

28760 $ 1,480.68 $ 1,065.76 90 10% 69% 21% 0 2 1 2 1 0 R

28800 $ 987.97 $ 987.97 90 10% 69% 21% 0 2 1 2 1 0 R

28805 $ 1,330.15 $ 1,330.15 90 10% 69% 21% 0 2 1 0 0 0 R

28810 $ 785.57 $ 785.57 90 10% 69% 21% 0 2 0 0 0 0 R

28820 $ 1,051.22 $ 725.48 90 10% 69% 21% 0 2 0 1 0 0 R

28825 $ 1,006.31 $ 681.84 90 10% 69% 21% 0 2 0 1 0 0 R



29000 $ 548.38 $ 323.84 0 0% 0% 0% 0 2 0 0 0 0 R

29010 $ 404.80 $ 253.00 0 0% 0% 0% 0 2 0 0 0 0 R

29015 $ 493.35 $ 309.93 0 0% 0% 0% 0 2 0 0 0 0 R

29035 $ 473.74 $ 263.12 0 0% 0% 0% 0 2 0 0 0 0 R

29040 $ 416.82 $ 266.28 0 0% 0% 0% 0 2 0 0 0 0 R

29044 $ 461.73 $ 279.57 0 0% 0% 0% 0 2 0 0 0 0 R

29046 $ 483.23 $ 302.97 0 0% 0% 0% 0 2 0 0 0 0 R

29049 $ 134.72 $ 102.47 0 0% 0% 0% 0 2 0 0 0 0 R

29055 $ 405.43 $ 250.47 0 0% 0% 0% 0 2 0 0 0 0 R

29058 $ 223.91 $ 170.14 0 0% 0% 0% 0 2 0 0 0 0 R

29065 $ 176.47 $ 124.60 0 0% 0% 0% 0 2 1 1 0 0 R

29075 $ 160.02 $ 113.85 0 0% 0% 0% 0 2 1 1 0 0 R

29085 $ 175.84 $ 123.97 0 0% 0% 0% 0 2 1 1 0 0 R

29086 $ 141.05 $ 91.71 0 0% 0% 0% 0 2 1 1 0 0 R

29105 $ 161.92 $ 108.79 0 0% 0% 0% 0 2 1 1 0 0 R

29125 $ 119.54 $ 72.11 0 0% 0% 0% 0 2 1 1 0 0 R

29126 $ 139.78 $ 87.92 0 0% 0% 0% 0 2 1 1 0 0 R

29130 $ 75.27 $ 51.87 0 0% 0% 0% 0 2 1 1 0 0 R

29131 $ 93.61 $ 60.09 0 0% 0% 0% 0 2 1 1 0 0 R

29200 $ 55.03 $ 32.89 0 0% 0% 0% 0 2 0 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


29240 $ 52.50 $ 32.89 0 0% 0% 0% 0 2 1 1 0 0 R

29260 $ 52.50 $ 35.42 0 0% 0% 0% 0 2 1 1 0 0 R

29280 $ 53.13 $ 35.42 0 0% 0% 0% 0 2 1 1 0 0 R

29305 $ 452.24 $ 289.05 0 0% 0% 0% 0 2 0 0 0 0 R

29325 $ 503.47 $ 324.47 0 0% 0% 0% 0 2 0 0 0 0 R

29345 $ 249.84 $ 184.06 0 0% 0% 0% 0 2 1 1 0 0 R

29355 $ 258.06 $ 194.18 0 0% 0% 0% 0 2 1 1 0 0 R

29358 $ 295.38 $ 188.49 0 0% 0% 0% 0 2 1 1 0 0 R

29365 $ 225.80 $ 159.39 0 0% 0% 0% 0 2 1 1 0 0 R

29405 $ 151.17 $ 110.06 0 0% 0% 0% 0 2 1 1 0 0 R

29425 $ 144.84 $ 104.36 0 0% 0% 0% 0 2 1 1 0 0 R

29435 $ 216.32 $ 151.80 0 0% 0% 0% 0 2 1 1 0 0 R

29440 $ 80.96 $ 52.50 0 0% 0% 0% 0 2 1 1 0 0 R

29445 $ 246.04 $ 189.75 0 0% 0% 0% 0 2 1 1 0 0 R


29505 $ 155.60 $ 91.08 0 0% 0% 0% 0 2 1 1 0 0 R

29515 $ 133.46 $ 91.08 0 0% 0% 0% 0 2 1 1 0 0 R

29520 $ 57.56 $ 33.52 0 0% 0% 0% 0 2 1 0 0 0 R

29530 $ 52.50 $ 32.89 0 0% 0% 0% 0 2 1 1 0 0 R

29540 $ 47.44 $ 32.89 0 0% 0% 0% 0 2 1 1 0 0 R

29550 $ 34.79 $ 20.87 0 0% 0% 0% 0 2 1 1 0 0 R

29580 $ 96.14 $ 64.52 0 0% 0% 0% 0 2 1 1 0 0 R

29581 $ 117.01 $ 23.40 0 0% 0% 0% 0 2 1 0 0 0 R

29582 $ 132.19 $ 28.46 0 0% 0% 0% 0 2 1 0 0 0 R

29583 $ 82.23 $ 20.24 0 0% 0% 0% 0 2 1 0 0 0 R

29584 $ 132.19 $ 28.46 0 0% 0% 0% 0 2 1 0 0 0 R

29700 $ 116.38 $ 60.72 0 0% 0% 0% 0 2 0 1 0 0 R

29705 $ 122.07 $ 85.39 0 0% 0% 0% 0 2 1 1 0 0 R

29710 $ 222.01 $ 149.90 0 0% 0% 0% 0 2 1 0 0 0 R

29720 $ 156.86 $ 80.33 0 0% 0% 0% 0 2 0 1 0 0 R

29730 $ 117.65 $ 80.96 0 0% 0% 0% 0 2 0 1 0 0 R

29740 $ 181.53 $ 127.13 0 0% 0% 0% 0 2 0 1 0 0 R



29800 $ 959.50 $ 959.50 90 10% 69% 21% 0 2 1 0 0 0 R Y

29804 $ 1,177.72 $ 1,177.72 90 10% 69% 21% 0 2 1 2 1 0 R Y

29805 $ 858.94 $ 858.94 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR

29806 $ 1,925.33 $ 1,925.33 90 10% 69% 21% 0 3 1 1 1 0 29805 R Y-UR

29807 $ 1,878.53 $ 1,878.53 90 10% 69% 21% 0 3 1 1 1 0 29805 R Y-UR

29819 $ 1,064.50 $ 1,064.50 90 10% 69% 21% 0 3 1 1 1 0 29805 R Y-UR

29820 $ 974.05 $ 974.05 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR

29821 $ 1,064.50 $ 1,064.50 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR

29822 $ 1,034.77 $ 1,034.77 90 10% 69% 21% 0 3 1 2 0 0 29805 R Y-UR

29823 $ 1,129.01 $ 1,129.01 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR

29824 $ 1,216.93 $ 1,216.93 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


29825 $ 1,053.11 $ 1,053.11 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR

29826 $ 318.15 $ 318.15 0 0% 0% 0% 0 0 1 2 1 0 R Y-UR

29827 $ 1,920.90 $ 1,920.90 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR

29828 $ 1,657.78 $ 1,657.78 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR

29830 $ 831.74 $ 831.74 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR

29834 $ 889.30 $ 889.30 90 10% 69% 21% 0 3 1 2 1 0 29830 R Y-UR

29835 $ 913.33 $ 913.33 90 10% 69% 21% 0 3 1 2 1 0 29830 R Y-UR

29836 $ 1,043.63 $ 1,043.63 90 10% 69% 21% 0 3 1 2 1 0 29830 R Y-UR

29837 $ 953.18 $ 953.18 90 10% 69% 21% 0 3 1 2 1 0 29830 R Y-UR

29838 $ 1,069.56 $ 1,069.56 90 10% 69% 21% 0 3 1 0 0 0 29830 R Y-UR

29840 $ 821.62 $ 821.62 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR

29843 $ 881.71 $ 881.71 90 10% 69% 21% 0 3 1 2 1 0 29840 R

29844 $ 905.11 $ 905.11 90 10% 69% 21% 0 3 1 2 0 0 29840 R

29845 $ 1,050.58 $ 1,050.58 90 10% 69% 21% 0 3 1 2 1 0 29840 R

29846 $ 948.12 $ 948.12 90 10% 69% 21% 0 3 1 0 0 0 29840 R Y-UR

29847 $ 984.80 $ 984.80 90 10% 69% 21% 0 3 1 2 0 0 29840 R

29848 $ 932.94 $ 932.94 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR

29850 $ 1,101.18 $ 1,101.18 90 10% 69% 21% 0 2 1 0 2 0 R

29851 $ 1,635.01 $ 1,635.01 90 10% 69% 21% 0 2 1 2 2 0 R

29855 $ 1,421.23 $ 1,421.23 90 10% 69% 21% 0 2 1 2 2 0 R

29856 $ 1,797.57 $ 1,797.57 90 10% 69% 21% 0 2 1 2 2 0 R

29860 $ 1,199.22 $ 1,199.22 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

29861 $ 1,313.07 $ 1,313.07 90 10% 69% 21% 0 3 1 2 1 0 29860 R Y-UR

29862 $ 1,469.93 $ 1,469.93 90 10% 69% 21% 0 3 1 2 1 0 29860 R Y-UR

29863 $ 1,468.67 $ 1,468.67 90 10% 69% 21% 0 3 1 2 1 0 29860 R Y-UR

29866 $ 1,884.22 $ 1,884.22 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR

29867 $ 2,321.28 $ 2,321.28 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR

29868 $ 2,982.24 $ 2,982.24 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR

29870 $ 1,072.72 $ 749.51 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR

29871 $ 936.10 $ 936.10 90 10% 69% 21% 0 3 1 1 0 0 29870 R Y-UR

29873 $ 955.08 $ 955.08 90 10% 69% 21% 0 3 1 1 1 0 29870 R Y-UR

29874 $ 977.21 $ 977.21 90 10% 69% 21% 0 3 1 0 0 0 29870 R Y-UR

29875 $ 901.31 $ 901.31 90 10% 69% 21% 0 3 1 0 0 0 29870 R Y-UR

29876 $ 1,194.79 $ 1,194.79 90 10% 69% 21% 0 3 1 1 0 0 29870 R Y-UR

29877 $ 1,130.28 $ 1,130.28 90 10% 69% 21% 0 3 1 2 0 0 29870 R Y-UR

29879 $ 1,204.28 $ 1,204.28 90 10% 69% 21% 0 3 1 0 0 0 29870 R Y-UR

29880 $ 1,024.02 $ 1,024.02 90 10% 69% 21% 0 3 1 0 1 0 29870 R Y-UR

29881 $ 986.07 $ 986.07 90 10% 69% 21% 0 3 1 2 0 0 29870 R Y-UR

29882 $ 1,273.86 $ 1,273.86 90 10% 69% 21% 0 3 1 1 0 0 29870 R Y-UR

29883 $ 1,533.81 $ 1,533.81 90 10% 69% 21% 0 3 1 0 0 0 29870 R Y-UR

29884 $ 1,119.53 $ 1,119.53 90 10% 69% 21% 0 3 1 2 1 0 29870 R Y-UR

29885 $ 1,358.61 $ 1,358.61 90 10% 69% 21% 0 3 1 2 1 0 29870 R Y-UR

29886 $ 1,154.31 $ 1,154.31 90 10% 69% 21% 0 3 1 1 0 0 29870 R Y-UR

29887 $ 1,345.33 $ 1,345.33 90 10% 69% 21% 0 3 1 2 1 0 29870 R Y-UR

29888 $ 1,787.45 $ 1,787.45 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


29889 $ 2,217.55 $ 2,217.55 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR

29891 $ 1,225.79 $ 1,225.79 90 10% 69% 21% 0 2 1 2 0 0 R Y

29892 $ 1,184.67 $ 1,184.67 90 10% 69% 21% 0 2 1 2 0 0 R Y

29893 $ 1,146.09 $ 790.63 90 10% 69% 21% 0 2 1 1 1 0 R Y

29894 $ 907.01 $ 907.01 90 10% 69% 21% 0 2 1 2 1 0 R Y

29895 $ 871.59 $ 871.59 90 10% 69% 21% 0 2 1 2 1 0 R Y

29897 $ 917.13 $ 917.13 90 10% 69% 21% 0 2 1 2 0 0 R Y

29898 $ 1,029.08 $ 1,029.08 90 10% 69% 21% 0 2 1 2 1 0 R Y

29899 $ 1,884.85 $ 1,884.85 90 10% 69% 21% 0 2 1 2 1 0 R Y

29900 $ 778.61 $ 778.61 90 10% 69% 21% 0 2 1 0 0 0 R Y

29901 $ 967.09 $ 967.09 90 10% 69% 21% 0 2 1 0 0 0 R Y

29902 $ 888.03 $ 888.03 90 10% 69% 21% 0 2 1 0 0 0 R Y

29904 $ 1,139.77 $ 1,139.77 90 10% 69% 21% 0 2 1 2 0 0 R Y

29905 $ 1,236.54 $ 1,236.54 90 10% 69% 21% 0 2 1 2 0 0 R Y

29906 $ 1,260.57 $ 1,260.57 90 10% 69% 21% 0 2 1 2 0 0 R Y

29907 $ 1,590.11 $ 1,590.11 90 10% 69% 21% 0 2 1 2 0 0 R Y

29914 Not Covered Not Covered 90 10% 69% 21% 0 3 1 2 1 0 29860 X


29916 $ 1,843.74 $ 1,843.74 90 10% 69% 21% 0 3 1 2 1 0 29860 R Y-UR


30000 $ 423.14 $ 214.42 10 10% 80% 10% 0 2 0 0 0 0 R

30020 $ 428.84 $ 216.32 10 10% 80% 10% 0 2 0 1 0 0 R

30100 $ 259.96 $ 125.24 0 0% 0% 0% 0 2 0 1 0 0 R

30110 $ 423.78 $ 236.56 10 10% 80% 10% 0 2 1 1 0 0 R

30115 $ 788.10 $ 788.10 90 10% 76% 14% 0 2 1 1 0 0 R

30117 $ 1,628.69 $ 623.01 90 10% 76% 14% 0 2 0 1 0 0 R

30118 $ 1,393.40 $ 1,393.40 90 10% 76% 14% 0 2 0 1 1 0 R




30130 $ 698.28 $ 698.28 90 10% 76% 14% 0 2 1 1 0 0 R

30140 $ 808.34 $ 808.34 90 10% 76% 14% 0 2 1 1 0 0 R

30150 $ 1,393.40 $ 1,393.40 90 10% 76% 14% 0 2 0 1 1 0 R

30160 $ 1,398.46 $ 1,398.46 90 10% 76% 14% 0 2 0 2 1 0 R

30200 $ 208.09 $ 108.16 0 0% 0% 0% 0 2 0 1 0 0 R

30210 $ 275.14 $ 181.53 10 10% 80% 10% 0 2 0 1 0 0 R

30220 $ 560.40 $ 227.07 10 10% 80% 10% 0 2 0 1 0 0 R

30300 $ 329.53 $ 194.18 10 10% 80% 10% 0 2 0 1 0 0 R

30310 $ 377.60 $ 377.60 10 10% 80% 10% 0 2 0 0 0 0 R

30320 $ 824.78 $ 824.78 90 10% 76% 14% 0 2 0 0 0 0 R

30400 $ 1,841.84 $ 1,841.84 90 10% 76% 14% 0 2 0 0 0 0 R

30410 $ 2,137.22 $ 2,137.22 90 10% 76% 14% 0 2 0 2 0 0 R

30420 $ 2,485.09 $ 2,485.09 90 10% 76% 14% 0 2 0 1 0 0 R

30430 $ 1,566.70 $ 1,566.70 90 10% 76% 14% 0 2 0 2 0 0 R

30435 $ 2,293.45 $ 2,293.45 90 10% 76% 14% 0 2 0 2 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


30450 $ 2,702.67 $ 2,702.67 90 10% 76% 14% 0 2 0 2 0 0 R



30465 $ 1,776.69 $ 1,776.69 90 10% 76% 14% 0 2 0 0 0 0 R

30520 $ 1,133.44 $ 1,133.44 90 10% 76% 14% 0 2 0 1 0 0 R



30560 $ 496.51 $ 251.10 10 10% 80% 10% 0 2 0 1 0 0 R

30580 $ 1,197.96 $ 932.94 90 10% 76% 14% 0 2 0 1 0 0 R

30600 $ 1,039.83 $ 774.18 90 10% 76% 14% 0 2 0 0 0 0 R

30620 $ 1,141.03 $ 1,141.03 90 10% 76% 14% 0 2 0 1 0 0 R

30630 $ 1,130.28 $ 1,130.28 90 10% 76% 14% 0 2 0 0 0 0 R

30801 $ 424.41 $ 251.10 10 10% 80% 10% 0 2 2 1 0 0 R

30802 $ 534.46 $ 346.61 10 10% 80% 10% 0 2 2 1 0 0 R

30901 $ 173.31 $ 101.83 0 0% 0% 0% 0 2 1 1 0 0 R

30903 $ 407.96 $ 144.84 0 0% 0% 0% 0 2 1 1 0 0 R

30905 $ 500.31 $ 191.02 0 0% 0% 0% 0 2 2 1 0 0 R

30906 $ 640.72 $ 246.68 0 0% 0% 0% 0 2 2 1 0 0 R

30915 $ 1,041.73 $ 1,041.73 90 10% 76% 14% 0 2 0 1 0 0 R

30920 $ 1,513.57 $ 1,513.57 90 10% 76% 14% 0 2 0 1 0 0 R

30930 $ 224.54 $ 224.54 10 10% 80% 10% 0 2 1 1 0 0 R


31000 $ 340.29 $ 193.55 10 10% 80% 10% 0 2 1 1 0 0 R

31002 $ 349.14 $ 349.14 10 10% 80% 10% 0 2 1 0 0 0 R

31020 $ 897.52 $ 662.23 90 10% 76% 14% 0 2 1 1 0 0 R

31030 $ 1,267.53 $ 963.93 90 10% 76% 14% 0 2 1 1 0 0 R

31032 $ 1,044.89 $ 1,044.89 90 10% 76% 14% 0 2 1 1 0 0 R

31040 $ 1,381.38 $ 1,381.38 90 10% 76% 14% 0 2 1 1 1 0 R

31050 $ 881.07 $ 881.07 90 10% 76% 14% 0 2 1 1 0 0 R

31051 $ 1,175.19 $ 1,175.19 90 10% 76% 14% 0 2 1 1 0 0 R

31070 $ 800.75 $ 800.75 90 10% 76% 14% 0 2 1 1 0 0 R

31075 $ 1,426.29 $ 1,426.29 90 10% 76% 14% 0 2 1 2 1 0 R

31080 $ 1,889.91 $ 1,889.91 90 10% 76% 14% 0 2 1 2 0 0 R

31081 $ 2,665.36 $ 2,665.36 90 10% 76% 14% 0 2 1 2 1 0 R

31084 $ 2,148.60 $ 2,148.60 90 10% 76% 14% 0 2 1 2 1 0 R

31085 $ 2,838.03 $ 2,838.03 90 10% 76% 14% 0 2 1 2 1 0 R

31086 $ 2,056.26 $ 2,056.26 90 10% 76% 14% 0 2 1 2 0 0 R

31087 $ 1,967.71 $ 1,967.71 90 10% 76% 14% 0 2 1 2 1 0 R

31090 $ 1,867.77 $ 1,867.77 90 10% 76% 14% 0 2 1 1 0 0 R

31200 $ 1,057.54 $ 1,057.54 90 10% 76% 14% 0 2 1 1 0 0 R

31201 $ 1,345.33 $ 1,345.33 90 10% 76% 14% 0 2 1 1 0 0 R

31205 $ 1,651.46 $ 1,651.46 90 10% 76% 14% 0 2 1 2 1 0 R



31231 $ 388.36 $ 117.65 0 0% 0% 0% 0 2 2 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


31233 $ 481.33 $ 247.31 0 0% 0% 0% 0 2 1 0 0 0 R

31235 $ 549.01 $ 292.22 0 0% 0% 0% 0 2 1 0 0 0 R

31237 $ 471.85 $ 291.58 0 0% 0% 0% 0 2 1 1 0 0 R

31238 $ 470.58 $ 305.50 0 0% 0% 0% 0 2 1 0 0 0 R

31239 $ 1,124.59 $ 1,124.59 10 10% 80% 10% 0 2 1 0 0 0 R


31254 $ 492.72 $ 492.72 0 0% 0% 0% 0 2 1 1 0 0 R

31255 $ 720.42 $ 720.42 0 0% 0% 0% 0 2 1 1 0 0 R

31256 $ 357.36 $ 357.36 0 0% 0% 0% 0 2 1 1 0 0 R

31267 $ 571.78 $ 571.78 0 0% 0% 0% 0 2 1 1 0 0 R

31276 $ 908.27 $ 908.27 0 0% 0% 0% 0 2 1 1 0 0 R

31287 $ 418.72 $ 418.72 0 0% 0% 0% 0 2 1 0 0 0 R

31288 $ 485.13 $ 485.13 0 0% 0% 0% 0 2 1 0 0 0 R

31290 $ 2,083.46 $ 2,083.46 10 10% 80% 10% 0 2 1 0 0 0 R

31291 $ 2,215.65 $ 2,215.65 10 10% 80% 10% 0 2 1 0 0 0 R

31292 $ 1,805.79 $ 1,805.79 10 10% 80% 10% 0 2 1 0 0 0 R

31293 $ 1,960.12 $ 1,960.12 10 10% 80% 10% 0 2 1 0 0 0 R

31294 $ 2,264.35 $ 2,264.35 10 10% 80% 10% 0 2 1 0 0 0 R

31295 $ 3,803.86 $ 296.01 0 0% 0% 0% 0 2 1 2 0 0 R

31296 $ 3,877.23 $ 354.20 0 0% 0% 0% 0 2 1 2 0 0 R

31297 $ 3,810.18 $ 290.32 0 0% 0% 0% 0 2 1 0 0 0 R
















31500 $ 254.27 $ 254.27 0 0% 0% 0% 0 0 0 1 0 0 R

31502 $ 63.88 $ 63.88 0 0% 0% 0% 0 2 0 1 0 0 R

31505 $ 152.43 $ 90.45 0 0% 0% 0% 0 2 0 1 0 0 R

31510 $ 390.25 $ 221.38 0 0% 0% 0% 0 3 0 0 0 0 31505 R

31511 $ 387.72 $ 235.29 0 0% 0% 0% 0 3 0 1 0 0 31505 R

31512 $ 378.87 $ 236.56 0 0% 0% 0% 0 3 0 0 0 0 31505 R

31513 $ 240.35 $ 240.35 0 0% 0% 0% 0 3 0 0 0 0 31505 R

31515 $ 335.23 $ 189.75 0 0% 0% 0% 0 2 0 1 0 0 R




Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


31525 $ 463.62 $ 290.95 0 0% 0% 0% 0 2 0 1 0 0 R

31526 $ 285.89 $ 285.89 0 0% 0% 0% 0 2 0 1 0 0 R

31527 $ 353.57 $ 353.57 0 0% 0% 0% 0 3 0 0 0 0 31525 R

31528 $ 263.12 $ 263.12 0 0% 0% 0% 0 3 0 0 0 0 31525 R

31529 $ 294.11 $ 294.11 0 0% 0% 0% 0 3 0 0 0 0 31525 R

31530 $ 359.89 $ 359.89 0 0% 0% 0% 0 3 0 1 0 0 31525 R

31531 $ 385.19 $ 385.19 0 0% 0% 0% 0 3 0 0 0 0 31526 R

31535 $ 344.08 $ 344.08 0 0% 0% 0% 0 3 0 1 0 0 31525 R

31536 $ 383.30 $ 383.30 0 0% 0% 0% 0 3 0 1 0 0 31526 R



31545 $ 658.43 $ 658.43 0 0% 0% 0% 0 3 1 1 0 0 31526 R

31546 $ 998.72 $ 998.72 0 0% 0% 0% 0 3 1 1 0 0 31526 R


31552 $ 2,624.24 $ 2,624.24 090 10% 76% 14% 0 2 0 0 1 0 R Y-UR


31554 $ 3,021.45 $ 3,021.45 090 10% 76% 14% 0 2 0 0 1 0 R Y-UR



31570 $ 617.95 $ 416.82 0 0% 0% 0% 0 3 0 1 0 0 31525 R

31571 $ 454.14 $ 454.14 0 0% 0% 0% 0 3 0 1 0 0 31526 R

31572 $ 924.72 $ 328.90 0 0% 0% 0% 0 3 1 0 0 0 31575 R Y

31573 $ 487.03 $ 271.98 0 0% 0% 0% 0 3 1 0 0 0 31575 R Y

31574 $ 1,929.13 $ 271.98 0 0% 0% 0% 0 3 1 0 0 0 31575 R Y

31575 $ 209.36 $ 123.34 0 0% 0% 0% 0 2 0 1 0 0 R

31576 $ 490.82 $ 217.58 0 0% 0% 0% 0 3 0 1 0 0 31575 R

31577 $ 506.63 $ 244.78 0 0% 0% 0% 0 3 0 0 0 0 31575 R

31578 $ 556.60 $ 271.98 0 0% 0% 0% 0 3 0 0 0 0 31575 R

31579 $ 324.47 $ 218.21 0 0% 0% 0% 0 3 0 1 0 0 31575 R



31587 $ 2,120.14 $ 2,120.14 90 10% 76% 14% 0 2 0 2 1 0 R

31590 $ 1,610.98 $ 1,610.98 90 10% 76% 14% 0 2 0 2 1 0 R

31591 $ 1,908.89 $ 1,908.89 090 10% 76% 14% 0 2 0 0 1 0 R Y-UR

31592 $ 3,071.42 $ 3,071.42 090 10% 76% 14% 0 2 0 0 1 0 R Y-UR



31600 $ 712.83 $ 712.83 0 0% 0% 0% 0 2 0 1 0 0 R


31603 $ 401.01 $ 401.01 0 0% 0% 0% 0 2 0 1 0 0 R

31605 $ 329.53 $ 329.53 0 0% 0% 0% 0 2 0 1 0 0 R

31610 $ 1,299.16 $ 1,299.16 90 10% 76% 14% 0 2 0 1 0 0 R

31611 $ 984.17 $ 984.17 90 10% 76% 14% 0 2 0 2 1 0 R

31612 $ 151.80 $ 86.65 0 0% 0% 0% 0 2 0 0 0 0 R

31613 $ 832.37 $ 832.37 90 10% 76% 14% 0 2 0 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


31614 $ 1,380.75 $ 1,380.75 90 10% 76% 14% 0 2 0 1 0 0 R

31615 $ 308.03 $ 209.36 0 0% 0% 0% 0 2 0 1 0 0 R

31622 $ 443.38 $ 240.35 0 0% 0% 0% 0 2 0 1 0 0 R

31623 $ 500.94 $ 245.41 0 0% 0% 0% 0 3 0 1 0 0 31622 R

31624 $ 467.42 $ 248.57 0 0% 0% 0% 0 3 0 1 0 0 31622 R

31625 $ 613.53 $ 286.52 0 0% 0% 0% 0 3 0 1 0 0 31622 R

31626 $ 1,573.03 $ 362.42 0 0% 0% 0% 0 2 0 0 0 0 R

31627 $ 2,632.47 $ 177.73 0 0% 0% 0% 0 0 0 0 0 0 R

31628 $ 650.21 $ 322.58 0 0% 0% 0% 0 3 0 1 0 0 31622 R

31629 $ 805.17 $ 342.82 0 0% 0% 0% 0 3 0 1 0 0 31622 R

31630 $ 363.69 $ 363.69 0 0% 0% 0% 0 3 0 1 0 0 31622 R

31631 $ 415.55 $ 415.55 0 0% 0% 0% 0 3 0 1 0 0 31622 R

31632 $ 117.65 $ 89.82 0 0% 0% 0% 0 0 0 1 0 0 R

31633 $ 146.11 $ 115.75 0 0% 0% 0% 0 0 0 1 0 0 R

31634 $ 3,371.23 $ 352.94 0 0% 0% 0% 0 3 0 2 0 0 31622 R

31635 $ 512.96 $ 320.05 0 0% 0% 0% 0 3 0 1 0 0 31622 R

31636 $ 401.01 $ 401.01 0 0% 0% 0% 0 3 0 1 0 0 31622 R

31637 $ 135.36 $ 135.36 0 0% 0% 0% 0 0 0 1 0 0 R

31638 $ 456.03 $ 456.03 0 0% 0% 0% 0 3 0 1 0 0 31622 R

31640 $ 459.20 $ 459.20 0 0% 0% 0% 0 3 0 1 0 0 31622 R Y

31641 $ 469.32 $ 469.32 0 0% 0% 0% 0 3 0 1 0 0 31622 R Y

31643 $ 324.47 $ 324.47 0 0% 0% 0% 0 2 0 1 0 0 R Y

31645 $ 468.68 $ 273.24 0 0% 0% 0% 0 3 0 1 0 0 31622 R

31646 $ 423.14 $ 233.39 0 0% 0% 0% 0 2 0 1 0 0 R

31647 $ 383.93 $ 383.93 0 0% 0% 0% 0 3 0 1 0 0 31622 R

31648 $ 352.30 $ 352.30 0 0% 0% 0% 0 3 0 1 0 0 31622 R

31649 $ 126.50 $ 126.50 0 0% 0% 0% 0 0 0 1 0 0 R

31651 $ 135.99 $ 135.99 0 0% 0% 0% 0 0 0 1 0 0 R

31652 $ 1,543.30 $ 405.43 0 0% 0% 0% 0 2 0 1 0 0 R

31653 $ 1,631.85 $ 449.08 0 0% 0% 0% 0 2 0 1 0 0 R

31654 $ 232.13 $ 123.34 0 0% 0% 0% 0 0 0 1 0 0 R



31717 $ 482.60 $ 197.97 0 0% 0% 0% 0 2 0 1 0 0 R

31720 $ 94.24 $ 94.24 0 0% 0% 0% 0 2 0 1 0 0 R

31725 $ 141.68 $ 141.68 0 0% 0% 0% 0 2 0 1 0 0 R

31730 $ 2,317.48 $ 267.55 0 0% 0% 0% 0 2 0 1 0 0 R

31750 $ 2,574.91 $ 2,574.91 90 10% 76% 14% 0 2 0 2 1 0 R

31755 $ 3,280.15 $ 3,280.15 90 10% 76% 14% 0 2 0 2 1 0 R

31760 $ 2,486.99 $ 2,486.99 90 10% 76% 14% 0 2 0 2 1 0 R

31766 $ 3,178.95 $ 3,178.95 90 10% 76% 14% 0 2 0 2 1 0 R

31770 $ 2,381.36 $ 2,381.36 90 10% 76% 14% 0 2 0 2 1 0 R

31775 $ 2,342.15 $ 2,342.15 90 10% 76% 14% 0 2 0 2 0 0 R

31780 $ 2,122.04 $ 2,122.04 90 10% 76% 14% 0 2 0 2 1 0 R

31781 $ 2,474.34 $ 2,474.34 90 10% 76% 14% 0 2 0 2 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY




31800 $ 1,349.12 $ 1,349.12 90 10% 76% 14% 0 2 0 0 0 0 R

31805 $ 1,468.03 $ 1,468.03 90 10% 76% 14% 0 2 0 2 1 0 R

31820 $ 793.16 $ 594.55 90 10% 76% 14% 0 2 0 0 0 0 R

31825 $ 1,094.86 $ 869.69 90 10% 76% 14% 0 2 0 0 0 0 R

31830 $ 808.97 $ 624.91 90 10% 76% 14% 0 2 0 0 0 0 R


32035 $ 1,306.11 $ 1,306.11 90 10% 76% 14% 0 2 1 2 1 0 R

32036 $ 1,390.87 $ 1,390.87 90 10% 76% 14% 0 2 1 2 1 0 R

32096 $ 1,444.00 $ 1,444.00 90 10% 76% 14% 0 2 0 2 1 0 R Y

32097 $ 1,440.84 $ 1,440.84 90 10% 76% 14% 0 2 0 2 1 0 R Y

32098 $ 1,366.83 $ 1,366.83 90 10% 76% 14% 0 2 0 2 1 0 R Y

32100 $ 1,452.85 $ 1,452.85 90 10% 76% 14% 0 2 0 2 1 0 R

32110 $ 2,619.82 $ 2,619.82 90 10% 76% 14% 0 2 0 2 1 0 R

32120 $ 1,564.81 $ 1,564.81 90 10% 76% 14% 0 2 0 2 1 0 R

32124 $ 1,662.21 $ 1,662.21 90 10% 76% 14% 0 2 0 2 1 0 R

32140 $ 1,765.31 $ 1,765.31 90 10% 76% 14% 0 2 0 2 1 0 R

32141 $ 2,722.28 $ 2,722.28 90 10% 76% 14% 0 2 0 2 1 0 R

32150 $ 1,801.99 $ 1,801.99 90 10% 76% 14% 0 2 0 2 1 0 R

32151 $ 1,797.57 $ 1,797.57 90 10% 76% 14% 0 2 0 2 1 0 R

32160 $ 1,420.60 $ 1,420.60 90 10% 76% 14% 0 2 0 2 1 0 R

32200 $ 2,031.59 $ 2,031.59 90 10% 76% 14% 0 2 0 2 1 0 R

32215 $ 1,432.61 $ 1,432.61 90 10% 76% 14% 0 2 1 2 1 0 R Y

32220 $ 2,838.03 $ 2,838.03 90 10% 76% 14% 0 2 1 2 1 0 R Y

32225 $ 1,780.49 $ 1,780.49 90 10% 76% 14% 0 2 1 2 1 0 R Y

32310 $ 1,640.07 $ 1,640.07 90 10% 76% 14% 0 2 0 2 1 0 R Y

32320 $ 2,860.17 $ 2,860.17 90 10% 76% 14% 0 2 0 2 1 0 R Y

32400 $ 277.67 $ 159.39 0 0% 0% 0% 0 2 0 1 0 0 R Y

32405 $ 726.74 $ 167.61 0 0% 0% 0% 0 2 0 1 0 0 R Y

32440 $ 2,798.18 $ 2,798.18 90 10% 76% 14% 0 2 0 2 1 0 R Y

32442 $ 5,474.29 $ 5,474.29 90 10% 76% 14% 0 2 0 2 1 0 R Y

32445 $ 6,322.47 $ 6,322.47 90 10% 76% 14% 0 2 0 2 1 0 R Y

32480 $ 2,643.85 $ 2,643.85 90 10% 76% 14% 0 2 0 2 1 0 R Y

32482 $ 2,830.44 $ 2,830.44 90 10% 76% 14% 0 2 0 2 1 0 R Y

32484 $ 2,564.79 $ 2,564.79 90 10% 76% 14% 0 2 0 2 1 0 R Y

32486 $ 4,191.58 $ 4,191.58 90 10% 76% 14% 0 2 0 2 1 0 R Y

32488 $ 4,288.98 $ 4,288.98 90 10% 76% 14% 0 2 0 2 1 0 R Y

32491 $ 2,635.63 $ 2,635.63 90 10% 76% 14% 0 2 1 2 1 0 R Y

32501 $ 435.79 $ 435.79 0 0% 0% 0% 0 0 0 2 1 0 R Y



32505 $ 1,669.17 $ 1,669.17 90 10% 76% 14% 0 2 0 2 1 0 R Y

32506 $ 278.30 $ 278.30 0 0% 0% 0% 0 0 0 2 1 0 R Y

32507 $ 278.30 $ 278.30 0 0% 0% 0% 0 0 0 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


32540 $ 3,101.78 $ 3,101.78 90 10% 76% 14% 0 2 0 2 1 0 R Y

32550 $ 1,323.19 $ 378.87 0 0% 0% 0% 0 0 0 1 0 0 R

32551 $ 283.36 $ 283.36 0 0% 0% 0% 0 2 1 1 0 0 R

32552 $ 335.86 $ 289.05 10 10% 80% 10% 0 2 0 0 0 0 R


32554 $ 373.18 $ 163.19 0 0% 0% 0% 0 2 1 1 0 0 R

32555 $ 538.26 $ 205.56 0 0% 0% 0% 0 2 1 1 0 0 R

32556 $ 1,033.51 $ 223.91 0 0% 0% 0% 0 2 1 1 0 0 R

32557 $ 952.55 $ 280.20 0 0% 0% 0% 0 2 1 1 0 0 R

32560 $ 451.61 $ 140.42 0 0% 0% 0% 0 2 0 1 0 0 R

32561 $ 168.25 $ 124.60 0 0% 0% 0% 0 2 0 2 0 0 R

32562 $ 150.54 $ 111.32 0 0% 0% 0% 0 2 0 2 0 0 R

32601 $ 552.17 $ 552.17 0 0% 0% 0% 0 2 0 0 0 0 R Y

32604 $ 861.47 $ 861.47 0 0% 0% 0% 0 2 0 0 0 0 R Y

32606 $ 826.05 $ 826.05 0 0% 0% 0% 0 2 0 0 0 0 R Y

32607 $ 552.17 $ 552.17 0 0% 0% 0% 0 2 0 0 0 0 R Y

32608 $ 676.78 $ 676.78 0 0% 0% 0% 0 2 0 0 0 0 R Y

32609 $ 464.26 $ 464.26 0 0% 0% 0% 0 2 0 0 0 0 R Y

32650 $ 1,196.06 $ 1,196.06 90 10% 76% 14% 0 2 1 2 1 0 R Y

32651 $ 1,960.75 $ 1,960.75 90 10% 76% 14% 0 2 1 2 1 0 R Y

32652 $ 2,970.85 $ 2,970.85 90 10% 76% 14% 0 2 1 2 1 0 R Y

32653 $ 1,896.24 $ 1,896.24 90 10% 76% 14% 0 2 0 2 1 0 R Y

32654 $ 2,114.45 $ 2,114.45 90 10% 76% 14% 0 2 1 2 1 0 R Y

32655 $ 1,713.44 $ 1,713.44 90 10% 76% 14% 0 2 1 2 1 0 R Y

32656 $ 1,437.67 $ 1,437.67 90 10% 76% 14% 0 2 1 2 1 0 R Y

32658 $ 1,280.18 $ 1,280.18 90 9% 84% 7% 0 2 0 2 1 0 R Y

32659 $ 1,313.70 $ 1,313.70 90 9% 84% 7% 0 2 0 2 1 0 R Y

32661 $ 1,431.35 $ 1,431.35 90 9% 84% 7% 0 2 0 2 1 0 R Y

32662 $ 1,600.23 $ 1,600.23 90 9% 84% 7% 0 2 0 2 1 0 R Y

32663 $ 2,504.07 $ 2,504.07 90 9% 84% 7% 0 2 0 2 1 0 R Y

32664 $ 1,516.10 $ 1,516.10 90 9% 84% 7% 0 2 1 2 1 0 R Y

32665 $ 2,210.59 $ 2,210.59 90 9% 81% 10% 0 2 0 2 1 0 R Y

32666 $ 1,561.64 $ 1,561.64 90 10% 76% 14% 0 2 0 2 1 0 R Y

32667 $ 279.57 $ 279.57 0 0% 0% 0% 0 0 0 2 1 0 R Y

32668 $ 279.57 $ 279.57 0 0% 0% 0% 0 0 0 2 1 0 R Y

32669 $ 2,405.40 $ 2,405.40 90 9% 84% 7% 0 2 0 2 1 0 R Y

32670 $ 2,865.23 $ 2,865.23 90 10% 76% 14% 0 2 0 2 1 0 R Y

32671 $ 3,173.25 $ 3,173.25 90 10% 76% 14% 0 2 0 2 1 0 R Y

32672 $ 2,722.28 $ 2,722.28 90 10% 76% 14% 0 2 0 2 1 0 R Y

32673 $ 2,176.43 $ 2,176.43 90 9% 82% 9% 0 2 0 2 1 0 R Y

32674 $ 384.56 $ 384.56 0 0% 0% 0% 0 0 0 2 1 0 R Y

32701 $ 383.30 $ 383.30 0 0% 0% 0% 2 0 0 0 1 0 R

32800 $ 1,699.53 $ 1,699.53 90 10% 76% 14% 0 2 0 2 1 0 R Y

32810 $ 1,602.12 $ 1,602.12 90 10% 76% 14% 0 2 0 2 0 0 R Y

32815 $ 4,982.84 $ 4,982.84 90 10% 76% 14% 0 2 0 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


32820 $ 2,527.47 $ 2,527.47 90 10% 76% 14% 0 2 0 2 1 0 R Y


32851 $ 5,886.68 $ 5,886.68 90 10% 76% 14% 0 2 0 2 1 2 R Y

32852 $ 6,423.04 $ 6,423.04 90 10% 76% 14% 0 2 0 2 1 2 R Y

32853 $ 8,195.94 $ 8,195.94 90 10% 76% 14% 0 2 2 2 1 2 R Y

32854 $ 8,700.04 $ 8,700.04 90 10% 76% 14% 0 2 2 2 1 2 R Y



32900 $ 2,526.21 $ 2,526.21 90 10% 76% 14% 0 2 0 2 1 0 R Y

32905 $ 2,405.40 $ 2,405.40 90 10% 76% 14% 0 2 0 2 1 0 R Y

32906 $ 2,960.10 $ 2,960.10 90 10% 76% 14% 0 2 0 2 1 0 R Y

32940 $ 2,213.12 $ 2,213.12 90 10% 76% 14% 0 2 0 2 1 0 R Y

32960 $ 235.29 $ 170.14 0 0% 0% 0% 0 2 0 1 0 0 R Y

32997 $ 624.91 $ 624.91 0 0% 0% 0% 0 2 1 1 0 0 R Y

32998 $ 3,634.98 $ 517.39 0 0% 0% 0% 0 2 1 2 0 0 R Y


33010 $ 191.65 $ 191.65 0 0% 0% 0% 0 2 0 1 0 0 R Y

33011 $ 193.55 $ 193.55 0 0% 0% 0% 0 2 0 0 0 0 R Y

33015 $ 923.45 $ 923.45 90 9% 84% 7% 0 2 0 1 0 0 R Y

33020 $ 1,579.35 $ 1,579.35 90 9% 84% 7% 0 2 0 2 1 0 R Y

33025 $ 1,430.72 $ 1,430.72 90 9% 84% 7% 0 2 0 2 1 0 R Y

33030 $ 3,581.22 $ 3,581.22 90 9% 84% 7% 0 2 0 2 1 0 R Y

33031 $ 4,417.38 $ 4,417.38 90 9% 84% 7% 0 2 0 2 1 0 R Y






33202 $ 1,390.87 $ 1,390.87 90 9% 84% 7% 0 2 0 1 0 0 R

33203 $ 1,440.84 $ 1,440.84 90 9% 84% 7% 0 2 0 1 0 0 R

33206 $ 814.03 $ 814.03 90 9% 84% 7% 0 2 0 1 2 0 R Y

33207 $ 866.53 $ 866.53 90 9% 84% 7% 0 2 0 1 2 0 R Y

33208 $ 939.90 $ 939.90 90 9% 84% 7% 0 2 0 1 2 0 R Y

33210 $ 296.64 $ 296.64 0 0% 0% 0% 0 2 0 1 0 0 R Y

33211 $ 302.97 $ 302.97 0 0% 0% 0% 0 2 0 1 0 0 R Y

33212 $ 578.11 $ 578.11 90 9% 84% 7% 0 2 0 1 0 0 R Y

33213 $ 604.67 $ 604.67 90 9% 84% 7% 0 2 0 1 0 0 R Y

33214 $ 862.73 $ 862.73 90 9% 84% 7% 0 2 0 0 2 0 R Y

33215 $ 561.03 $ 561.03 90 9% 84% 7% 0 2 0 1 0 0 R Y

33216 $ 669.82 $ 669.82 90 9% 84% 7% 0 2 0 1 0 0 R Y

33217 $ 656.54 $ 656.54 90 9% 84% 7% 0 2 0 1 0 0 R Y

33218 $ 704.61 $ 704.61 90 9% 84% 7% 0 2 0 1 0 0 R Y

33220 $ 704.61 $ 704.61 90 9% 84% 7% 0 2 0 1 0 0 R Y

33221 $ 652.11 $ 652.11 90 9% 84% 7% 0 2 0 1 0 0 R Y

33222 $ 610.36 $ 610.36 90 9% 84% 7% 0 2 0 1 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


33223 $ 736.86 $ 736.86 90 9% 84% 7% 0 2 0 0 0 0 R Y

33224 $ 927.88 $ 927.88 0 0% 0% 0% 0 2 0 1 0 0 R Y

33225 $ 845.02 $ 845.02 0 0% 0% 0% 0 0 0 1 0 0 R Y

33226 $ 893.09 $ 893.09 0 0% 0% 0% 0 2 0 1 0 0 R Y

33227 $ 609.73 $ 609.73 90 9% 84% 7% 0 2 0 1 0 0 R Y

33228 $ 637.56 $ 637.56 90 9% 84% 7% 0 2 0 1 0 0 R Y

33229 $ 676.14 $ 676.14 90 9% 84% 7% 0 2 0 1 0 0 R Y

33230 $ 690.69 $ 690.69 90 9% 84% 7% 0 2 0 1 0 0 R Y

33231 $ 726.74 $ 726.74 90 9% 84% 7% 0 2 0 1 0 0 R Y

33233 $ 418.08 $ 418.08 90 9% 84% 7% 0 2 0 1 0 0 R Y

33234 $ 876.01 $ 876.01 90 9% 84% 7% 0 2 0 1 0 0 R Y

33235 $ 1,151.78 $ 1,151.78 90 9% 84% 7% 0 2 0 1 0 0 R Y

33236 $ 1,409.21 $ 1,409.21 90 9% 84% 7% 0 2 0 0 2 0 R Y

33237 $ 1,504.72 $ 1,504.72 90 9% 84% 7% 0 2 0 0 2 0 R Y

33238 $ 1,680.55 $ 1,680.55 90 9% 84% 7% 0 2 0 0 2 0 R Y

33240 $ 659.07 $ 659.07 90 9% 84% 7% 0 2 0 1 0 0 R Y

33241 $ 390.89 $ 390.89 90 9% 84% 7% 0 2 0 1 0 0 R Y

33243 $ 2,456.63 $ 2,456.63 90 9% 84% 7% 0 2 0 2 1 0 R Y

33244 $ 1,551.52 $ 1,551.52 90 9% 84% 7% 0 2 0 1 1 0 R Y

33249 $ 1,652.72 $ 1,652.72 90 9% 84% 7% 0 2 0 1 1 0 R Y

33250 $ 2,609.06 $ 2,609.06 90 9% 84% 7% 0 2 0 2 1 0 R Y

33251 $ 2,902.54 $ 2,902.54 90 9% 84% 7% 0 2 0 2 1 0 R Y

33254 $ 2,443.98 $ 2,443.98 90 9% 84% 7% 0 2 0 2 1 0 R Y

33255 $ 2,939.23 $ 2,939.23 90 9% 84% 7% 0 2 0 2 1 0 R Y

33256 $ 3,478.12 $ 3,478.12 90 9% 84% 7% 0 2 0 2 1 0 R Y

33257 $ 1,047.42 $ 1,047.42 0 0% 0% 0% 0 0 0 2 0 0 R Y

33258 $ 1,176.45 $ 1,176.45 0 0% 0% 0% 0 0 0 2 0 0 R Y

33259 $ 1,518.63 $ 1,518.63 0 0% 0% 0% 0 0 0 2 0 0 R Y

33261 $ 2,901.91 $ 2,901.91 90 9% 84% 7% 0 2 0 2 1 0 R Y

33262 $ 673.61 $ 673.61 90 9% 84% 7% 0 2 0 1 0 0 R Y

33263 $ 700.81 $ 700.81 90 9% 84% 7% 0 2 0 1 0 0 R Y

33264 $ 731.17 $ 731.17 90 9% 84% 7% 0 2 0 1 0 0 R Y

33265 $ 2,435.76 $ 2,435.76 90 9% 84% 7% 0 2 0 2 1 0 R Y

33266 $ 3,304.81 $ 3,304.81 90 9% 84% 7% 0 2 0 2 1 0 R Y

33270 $ 1,067.03 $ 1,067.03 90 9% 84% 7% 0 2 0 1 0 0 R Y

33271 $ 896.25 $ 896.25 90 9% 84% 7% 0 2 0 1 0 0 R Y

33272 $ 631.24 $ 631.24 90 9% 84% 7% 0 2 0 1 0 0 R Y

33273 $ 737.50 $ 737.50 90 9% 84% 7% 0 2 0 1 0 0 R Y

33282 $ 409.23 $ 409.23 90 9% 84% 7% 0 2 0 1 0 0 R Y

33284 $ 359.89 $ 359.89 90 9% 84% 7% 0 2 0 1 0 0 R Y

33300 $ 4,378.80 $ 4,378.80 90 9% 84% 7% 0 2 0 2 1 0 R Y

33305 $ 7,315.50 $ 7,315.50 90 9% 84% 7% 0 2 0 2 1 0 R Y

33310 $ 2,127.10 $ 2,127.10 90 9% 84% 7% 0 2 0 2 1 0 R Y

33315 $ 3,420.56 $ 3,420.56 90 9% 84% 7% 0 2 0 2 1 0 R Y

33320 $ 1,905.09 $ 1,905.09 90 9% 84% 7% 0 2 0 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


33321 $ 2,137.22 $ 2,137.22 90 9% 84% 7% 0 2 0 2 1 0 R Y

33322 $ 2,488.89 $ 2,488.89 90 9% 84% 7% 0 2 0 2 1 0 R Y

33330 $ 2,560.36 $ 2,560.36 90 9% 84% 7% 0 2 0 2 1 0 R Y

33335 $ 3,358.58 $ 3,358.58 90 9% 84% 7% 0 2 0 2 1 0 R Y

33340 $ 1,437.67 $ 1,437.67 0 0% 0% 0% 0 2 0 0 2 1 R Y-UR










33390 $ 3,423.72 $ 3,423.72 090 9% 84% 7% 0 2 0 2 1 0 R Y-UR

33391 $ 4,056.86 $ 4,056.86 090 9% 84% 7% 0 2 0 2 1 0 R Y-UR

33404 $ 3,146.69 $ 3,146.69 90 9% 84% 7% 0 2 0 2 1 0 R Y

33405 $ 4,059.39 $ 4,059.39 90 9% 84% 7% 0 2 0 2 1 0 R Y

33406 $ 5,145.39 $ 5,145.39 90 9% 84% 7% 0 2 0 2 1 0 R Y

33410 $ 4,550.21 $ 4,550.21 90 9% 84% 7% 0 2 0 2 1 0 R Y

33411 $ 5,999.26 $ 5,999.26 90 9% 84% 7% 0 2 0 2 0 0 R Y

33412 $ 5,662.14 $ 5,662.14 90 9% 84% 7% 0 2 0 2 1 0 R Y

33413 $ 5,927.16 $ 5,927.16 90 9% 84% 7% 0 2 0 2 1 0 R Y

33414 $ 3,855.09 $ 3,855.09 90 9% 84% 7% 0 2 0 2 1 0 R Y

33415 $ 3,643.83 $ 3,643.83 90 9% 84% 7% 0 2 0 2 1 0 R Y

33416 $ 3,634.98 $ 3,634.98 90 9% 84% 7% 0 2 0 2 1 0 R Y

33417 $ 2,996.15 $ 2,996.15 90 9% 84% 7% 0 2 0 2 1 0 R Y

33418 $ 3,240.93 $ 3,240.93 90 9% 84% 7% 0 2 0 2 1 0 R Y

33419 $ 763.43 $ 763.43 0 0% 0% 0% 0 0 0 2 1 0 R Y

33420 $ 2,614.12 $ 2,614.12 90 9% 84% 7% 0 2 0 1 1 0 R Y

33422 $ 2,991.09 $ 2,991.09 90 9% 84% 7% 0 2 0 2 1 0 R Y

33425 $ 4,886.70 $ 4,886.70 90 9% 84% 7% 0 2 0 2 1 0 R Y

33426 $ 4,262.42 $ 4,262.42 90 9% 84% 7% 0 2 0 2 1 0 R Y

33427 $ 4,374.37 $ 4,374.37 90 9% 84% 7% 0 2 0 2 1 0 R Y

33430 $ 5,005.61 $ 5,005.61 90 9% 84% 7% 0 2 0 2 1 0 R Y

33460 $ 4,335.79 $ 4,335.79 90 9% 84% 7% 0 2 0 2 1 0 R Y

33463 $ 5,525.52 $ 5,525.52 90 9% 84% 7% 0 2 0 2 1 0 R Y

33464 $ 4,370.58 $ 4,370.58 90 9% 84% 7% 0 2 0 2 1 0 R Y

33465 $ 4,931.60 $ 4,931.60 90 9% 84% 7% 0 2 0 2 1 0 R Y

33468 $ 4,392.71 $ 4,392.71 90 9% 84% 7% 0 2 0 2 1 0 R Y

33470 $ 2,335.82 $ 2,335.82 90 9% 84% 7% 0 2 0 2 0 0 R Y

33471 $ 2,497.11 $ 2,497.11 90 9% 84% 7% 0 2 0 2 1 0 R Y

33474 $ 3,906.95 $ 3,906.95 90 9% 84% 7% 0 2 0 2 1 0 R Y

33475 $ 4,169.44 $ 4,169.44 90 9% 84% 7% 0 2 0 2 1 0 R Y

33476 $ 2,734.93 $ 2,734.93 90 9% 84% 7% 0 2 0 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


33477 $ 2,368.71 $ 2,368.71 0 0% 0% 0% 0 2 0 0 1 1 R Y

33478 $ 2,826.01 $ 2,826.01 90 9% 84% 7% 0 2 0 2 1 0 R Y

33496 $ 2,996.79 $ 2,996.79 90 9% 84% 7% 0 2 0 2 1 0 R Y

33500 $ 2,800.71 $ 2,800.71 90 9% 84% 7% 0 2 0 2 1 0 R Y

33501 $ 1,993.01 $ 1,993.01 90 9% 84% 7% 0 2 0 2 2 0 R Y

33502 $ 2,296.61 $ 2,296.61 90 9% 84% 7% 0 2 0 2 1 0 R Y

33503 $ 2,387.69 $ 2,387.69 90 9% 84% 7% 0 2 0 0 1 0 R Y

33504 $ 2,635.63 $ 2,635.63 90 9% 84% 7% 0 2 0 2 1 0 R Y

33505 $ 3,695.07 $ 3,695.07 90 9% 84% 7% 0 2 0 2 1 0 R Y

33506 $ 3,681.78 $ 3,681.78 90 9% 84% 7% 0 2 0 2 1 0 R Y

33507 $ 3,091.66 $ 3,091.66 90 9% 84% 7% 0 2 0 2 1 0 R

33508 $ 29.10 $ 29.10 0 0% 0% 0% 0 0 0 2 1 0 R Y

33510 $ 3,458.51 $ 3,458.51 90 9% 84% 7% 0 2 0 2 0 0 R Y

33511 $ 3,800.69 $ 3,800.69 90 9% 84% 7% 0 2 0 2 0 0 R Y

33512 $ 4,318.08 $ 4,318.08 90 9% 84% 7% 0 2 0 2 0 0 R Y

33513 $ 4,443.95 $ 4,443.95 90 9% 84% 7% 0 2 0 2 0 0 R Y

33514 $ 4,691.25 $ 4,691.25 90 9% 84% 7% 0 2 0 2 0 0 R Y

33516 $ 4,903.77 $ 4,903.77 90 9% 84% 7% 0 2 0 2 0 0 R Y

33517 $ 334.59 $ 334.59 0 0% 0% 0% 0 0 0 2 0 0 R Y

33518 $ 734.33 $ 734.33 0 0% 0% 0% 0 0 0 2 0 0 R Y

33519 $ 971.52 $ 971.52 0 0% 0% 0% 0 0 0 2 0 0 R Y

33521 $ 1,165.07 $ 1,165.07 0 0% 0% 0% 0 0 0 2 0 0 R Y

33522 $ 1,308.01 $ 1,308.01 0 0% 0% 0% 0 0 0 2 0 0 R Y

33523 $ 1,482.58 $ 1,482.58 0 0% 0% 0% 0 0 0 2 0 0 R Y

33530 $ 938.00 $ 938.00 0 0% 0% 0% 0 0 0 2 0 0 R Y

33533 $ 3,344.66 $ 3,344.66 90 9% 82% 9% 0 2 0 2 0 0 R Y

33534 $ 3,933.52 $ 3,933.52 90 9% 82% 9% 0 2 0 2 0 0 R Y

33535 $ 4,389.55 $ 4,389.55 90 9% 82% 9% 0 2 0 2 0 0 R Y

33536 $ 4,731.10 $ 4,731.10 90 9% 82% 9% 0 2 0 2 0 0 R Y

33542 $ 4,693.78 $ 4,693.78 90 9% 84% 7% 0 2 0 2 1 0 R Y

33545 $ 5,532.48 $ 5,532.48 90 9% 84% 7% 0 2 0 2 1 0 R Y

33548 $ 5,305.41 $ 5,305.41 90 9% 84% 7% 0 2 0 2 1 0 R

33572 $ 410.49 $ 410.49 0 0% 0% 0% 0 0 0 2 0 0 R Y

33600 $ 3,086.60 $ 3,086.60 90 9% 84% 7% 0 2 0 2 1 0 R Y

33602 $ 2,996.79 $ 2,996.79 90 9% 84% 7% 0 2 0 2 1 0 R Y

33606 $ 3,192.86 $ 3,192.86 90 9% 84% 7% 0 2 0 2 1 0 R Y

33608 $ 3,232.71 $ 3,232.71 90 9% 84% 7% 0 2 0 2 1 0 R Y

33610 $ 3,189.07 $ 3,189.07 90 9% 84% 7% 0 2 0 2 1 0 R Y

33611 $ 3,501.52 $ 3,501.52 90 9% 84% 7% 0 2 0 2 1 0 R Y

33612 $ 3,594.50 $ 3,594.50 90 9% 84% 7% 0 2 0 2 1 0 R Y

33615 $ 3,583.11 $ 3,583.11 90 9% 84% 7% 0 2 0 2 1 0 R Y

33617 $ 3,881.02 $ 3,881.02 90 9% 84% 7% 0 2 0 2 1 0 R Y

33619 $ 4,894.29 $ 4,894.29 90 9% 84% 7% 0 2 0 2 1 0 R Y

33620 $ 2,962.00 $ 2,962.00 90 9% 84% 7% 0 2 0 2 1 0 R Y

33621 $ 1,674.23 $ 1,674.23 90 9% 84% 7% 0 2 0 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY



33641 $ 2,943.66 $ 2,943.66 90 9% 84% 7% 0 2 0 2 1 0 R Y

33645 $ 3,105.58 $ 3,105.58 90 9% 84% 7% 0 2 0 2 1 0 R Y

33647 $ 3,261.80 $ 3,261.80 90 9% 84% 7% 0 2 0 2 1 0 R Y

33660 $ 3,152.38 $ 3,152.38 90 9% 84% 7% 0 2 0 2 1 0 R Y

33665 $ 3,533.78 $ 3,533.78 90 9% 84% 7% 0 2 0 2 1 0 R Y

33670 $ 3,536.31 $ 3,536.31 90 9% 84% 7% 0 2 0 2 1 0 R Y

33675 $ 3,538.84 $ 3,538.84 90 9% 84% 7% 0 2 0 2 1 0 R Y

33676 $ 3,849.40 $ 3,849.40 90 9% 84% 7% 0 2 0 2 1 0 R Y

33677 $ 3,998.67 $ 3,998.67 90 9% 84% 7% 0 2 0 2 1 0 R Y

33681 $ 3,304.81 $ 3,304.81 90 9% 84% 7% 0 2 0 2 1 0 R Y

33684 $ 3,389.57 $ 3,389.57 90 9% 84% 7% 0 2 0 2 1 0 R Y

33688 $ 3,587.54 $ 3,587.54 90 9% 84% 7% 0 2 0 2 1 0 R Y

33690 $ 2,160.62 $ 2,160.62 90 9% 84% 7% 0 2 0 2 1 0 R Y




33702 $ 2,777.31 $ 2,777.31 90 9% 84% 7% 0 2 0 2 1 0 R Y

33710 $ 3,681.15 $ 3,681.15 90 9% 84% 7% 0 2 0 2 0 0 R Y

33720 $ 2,779.21 $ 2,779.21 90 9% 84% 7% 0 2 0 2 1 0 R Y

33722 $ 2,917.72 $ 2,917.72 90 9% 84% 7% 0 2 0 2 1 0 R Y

33724 $ 2,764.66 $ 2,764.66 90 9% 84% 7% 0 2 0 2 1 0 R Y

33726 $ 3,648.26 $ 3,648.26 90 9% 84% 7% 0 2 0 2 1 0 R Y












33768 $ 797.58 $ 797.58 0 0% 0% 0% 0 0 0 2 2 0 R













Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY



















33860 $ 5,741.84 $ 5,741.84 90 9% 84% 7% 0 2 0 2 1 0 R Y

33863 $ 5,629.88 $ 5,629.88 90 9% 84% 7% 0 2 0 2 1 0 R Y

33864 $ 5,770.30 $ 5,770.30 90 9% 84% 7% 0 2 0 2 1 0 R Y

33870 $ 4,519.85 $ 4,519.85 90 9% 84% 7% 0 2 0 2 1 0 R Y

33875 $ 4,897.45 $ 4,897.45 90 9% 84% 7% 0 2 0 2 2 0 R Y

33877 $ 6,489.45 $ 6,489.45 90 9% 84% 7% 0 2 0 2 2 0 R Y

33880 $ 3,225.12 $ 3,225.12 90 9% 84% 7% 0 2 2 2 2 0 R

33881 $ 2,770.98 $ 2,770.98 90 9% 84% 7% 0 2 2 2 2 0 R

33883 $ 2,015.15 $ 2,015.15 90 9% 84% 7% 0 2 0 2 2 0 R

33884 $ 738.13 $ 738.13 0 0% 0% 0% 0 0 0 2 2 0 R

33886 $ 1,733.05 $ 1,733.05 90 9% 84% 7% 0 2 0 2 2 0 R

33889 $ 1,408.58 $ 1,408.58 0 0% 0% 0% 0 2 1 2 2 0 R

33891 $ 1,744.44 $ 1,744.44 0 0% 0% 0% 0 2 1 2 2 0 R

33910 $ 4,715.29 $ 4,715.29 90 9% 84% 7% 0 2 0 2 1 0 R Y

33915 $ 2,261.19 $ 2,261.19 90 9% 84% 7% 0 2 0 2 1 0 R Y

33916 $ 7,495.13 $ 7,495.13 90 9% 84% 7% 0 2 0 2 1 0 R Y

33917 $ 2,620.45 $ 2,620.45 90 9% 84% 7% 0 2 0 2 1 0 R Y


33922 $ 2,497.11 $ 2,497.11 90 9% 84% 7% 0 2 0 2 1 0 R Y









33945 $ 8,687.39 $ 8,687.39 90 9% 84% 7% 0 2 0 2 1 2 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


33946 $ 554.07 $ 554.07 0 0% 0% 0% 0 0 0 1 0 0 R Y

33947 $ 614.16 $ 614.16 0 0% 0% 0% 0 0 0 1 0 0 R Y

33948 $ 432.00 $ 432.00 0 0% 0% 0% 0 0 0 1 0 0 R Y

33949 $ 421.88 $ 421.88 0 0% 0% 0% 0 0 0 1 0 0 R Y


33952 $ 765.96 $ 765.96 0 0% 0% 0% 0 2 0 0 0 0 R Y


33954 $ 854.51 $ 854.51 0 0% 0% 0% 0 2 0 0 0 0 R Y


33956 $ 1,492.07 $ 1,492.07 0 0% 0% 0% 0 2 0 0 1 1 R Y


33958 $ 331.43 $ 331.43 0 0% 0% 0% 0 2 0 0 0 0 R Y


33962 $ 423.14 $ 423.14 0 0% 0% 0% 0 2 0 0 0 0 R Y


33964 $ 881.07 $ 881.07 0 0% 0% 0% 0 2 0 0 1 1 R Y


33966 $ 423.78 $ 423.78 0 0% 0% 0% 0 2 0 0 0 0 R Y

33967 $ 464.89 $ 464.89 0 0% 0% 0% 0 2 0 0 0 0 R Y

33968 $ 60.72 $ 60.72 0 0% 0% 0% 0 0 0 1 0 0 R Y


33970 $ 635.03 $ 635.03 0 0% 0% 0% 0 2 0 2 1 0 R Y

33971 $ 1,278.92 $ 1,278.92 90 9% 84% 7% 0 2 0 1 0 0 R Y

33973 $ 921.55 $ 921.55 0 0% 0% 0% 0 2 0 2 1 0 R Y

33974 $ 1,609.71 $ 1,609.71 90 9% 84% 7% 0 2 0 1 0 0 R Y

33975 $ 2,338.99 $ 2,338.99 0 0% 0% 0% 0 2 0 2 0 0 R Y

33976 $ 2,846.25 $ 2,846.25 0 0% 0% 0% 0 2 2 2 0 0 R Y

33977 $ 2,018.94 $ 2,018.94 0 0% 0% 0% 0 2 0 2 0 0 R Y

33978 $ 2,385.16 $ 2,385.16 0 0% 0% 0% 0 2 2 2 0 0 R Y

33979 $ 3,486.97 $ 3,486.97 0 0% 0% 0% 0 2 0 2 0 0 R Y

33980 $ 3,192.23 $ 3,192.23 0 0% 0% 0% 0 2 0 2 0 0 R Y

33981 $ 1,482.58 $ 1,482.58 0 0% 0% 0% 0 2 0 2 0 0 R Y

33982 $ 3,502.79 $ 3,502.79 0 0% 0% 0% 0 2 0 2 0 0 R Y

33983 $ 4,138.45 $ 4,138.45 0 0% 0% 0% 0 2 0 2 0 0 R Y

33984 $ 512.33 $ 512.33 0 0% 0% 0% 0 2 0 0 0 0 R


33986 $ 932.94 $ 932.94 0 0% 0% 0% 0 2 0 0 1 1 R Y

33987 $ 374.44 $ 374.44 0 0% 0% 0% 0 0 0 0 1 1 R Y

33988 $ 1,400.99 $ 1,400.99 0 0% 0% 0% 0 2 0 0 1 1 R Y

33989 $ 886.77 $ 886.77 0 0% 0% 0% 0 2 0 0 1 1 R Y

33990 $ 763.43 $ 763.43 0 0% 0% 0% 0 2 0 2 0 0 R

33991 $ 1,117.63 $ 1,117.63 0 0% 0% 0% 0 2 0 2 0 0 R

33992 $ 359.26 $ 359.26 0 0% 0% 0% 0 2 0 2 0 0 R

33993 $ 313.72 $ 313.72 0 0% 0% 0% 0 2 0 2 0 0 R




Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


34001 $ 1,746.33 $ 1,746.33 90 9% 84% 7% 0 2 1 2 1 0 R Y

34051 $ 1,593.90 $ 1,593.90 90 9% 84% 7% 0 2 1 2 1 0 R Y

34101 $ 1,081.58 $ 1,081.58 90 9% 84% 7% 0 2 1 2 1 0 R Y

34111 $ 1,080.94 $ 1,080.94 90 9% 84% 7% 0 2 1 2 1 0 R Y

34151 $ 2,524.31 $ 2,524.31 90 9% 84% 7% 0 2 1 2 1 0 R Y

34201 $ 1,855.12 $ 1,855.12 90 9% 84% 7% 0 2 1 2 1 0 R Y

34203 $ 1,719.14 $ 1,719.14 90 9% 84% 7% 0 2 1 2 1 0 R Y

34401 $ 2,636.89 $ 2,636.89 90 9% 84% 7% 0 2 1 2 1 0 R Y

34421 $ 1,308.64 $ 1,308.64 90 9% 84% 7% 0 2 1 2 1 0 R Y

34451 $ 2,944.92 $ 2,944.92 90 9% 84% 7% 0 2 1 2 1 0 R Y

34471 $ 1,958.85 $ 1,958.85 90 9% 84% 7% 0 2 1 1 1 0 R Y

34490 $ 1,097.39 $ 1,097.39 90 9% 84% 7% 0 2 1 1 0 0 R Y

34501 $ 1,623.63 $ 1,623.63 90 9% 84% 7% 0 2 1 2 1 0 R Y

34502 $ 2,775.41 $ 2,775.41 90 9% 84% 7% 0 2 0 2 0 0 R Y

34510 $ 2,158.09 $ 2,158.09 90 9% 84% 7% 0 2 1 2 1 0 R Y

34520 $ 1,902.56 $ 1,902.56 90 9% 84% 7% 0 2 1 2 1 0 R Y

34530 $ 1,708.38 $ 1,708.38 90 9% 84% 7% 0 2 1 2 1 0 R Y

34800 $ 2,033.49 $ 2,033.49 90 9% 84% 7% 0 2 0 2 2 0 R Y

34802 $ 2,246.01 $ 2,246.01 90 9% 84% 7% 0 2 0 2 2 0 R Y

34803 $ 2,326.97 $ 2,326.97 90 9% 84% 7% 0 2 2 2 2 0 R Y

34804 $ 2,247.91 $ 2,247.91 90 9% 84% 7% 0 2 0 2 2 0 R Y

34805 $ 2,144.81 $ 2,144.81 90 9% 84% 7% 0 2 0 2 2 0 R Y

34806 $ 177.73 $ 177.73 0 0% 0% 0% 0 0 0 2 2 0 R Y

34808 $ 371.28 $ 371.28 0 0% 0% 0% 0 0 0 2 2 0 R Y

34812 $ 604.04 $ 604.04 0 0% 0% 0% 0 2 1 2 2 0 R Y

34813 $ 422.51 $ 422.51 0 0% 0% 0% 0 0 0 2 2 0 R Y

34820 $ 876.65 $ 876.65 0 0% 0% 0% 0 2 1 2 2 0 R Y

34825 $ 1,258.04 $ 1,258.04 90 9% 84% 7% 0 2 0 2 2 0 R Y

34826 $ 368.75 $ 368.75 0 0% 0% 0% 0 0 0 2 2 0 R Y

34830 $ 3,224.49 $ 3,224.49 90 9% 84% 7% 0 2 0 2 2 0 R Y

34831 $ 3,410.44 $ 3,410.44 90 9% 84% 7% 0 2 0 2 2 0 R Y

34832 $ 3,391.47 $ 3,391.47 90 9% 84% 7% 0 2 0 2 2 0 R Y

34833 $ 1,090.43 $ 1,090.43 0 0% 0% 0% 0 2 1 2 2 0 R Y

34834 $ 488.29 $ 488.29 0 0% 0% 0% 0 2 1 2 2 0 R Y










34900 $ 1,610.35 $ 1,610.35 90 9% 84% 7% 0 2 1 2 2 0 R Y

35001 $ 2,010.72 $ 2,010.72 90 9% 84% 7% 0 2 1 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


35002 $ 2,062.58 $ 2,062.58 90 9% 84% 7% 0 2 1 2 1 0 R Y

35005 $ 2,030.33 $ 2,030.33 90 9% 84% 7% 0 2 1 2 1 0 R Y

35011 $ 1,812.75 $ 1,812.75 90 9% 84% 7% 0 2 1 2 1 0 R Y

35013 $ 2,259.29 $ 2,259.29 90 9% 84% 7% 0 2 1 2 1 0 R Y

35021 $ 2,230.83 $ 2,230.83 90 9% 84% 7% 0 2 1 2 1 0 R Y

35022 $ 2,579.97 $ 2,579.97 90 9% 84% 7% 0 2 1 2 1 0 R Y

35045 $ 1,784.92 $ 1,784.92 90 9% 84% 7% 0 2 1 2 1 0 R Y

35081 $ 3,135.30 $ 3,135.30 90 9% 84% 7% 0 2 0 2 1 0 R Y

35082 $ 3,947.43 $ 3,947.43 90 9% 84% 7% 0 2 0 2 1 0 R Y

35091 $ 3,215.00 $ 3,215.00 90 9% 84% 7% 0 2 1 2 1 0 R Y

35092 $ 4,677.34 $ 4,677.34 90 9% 84% 7% 0 2 1 2 1 0 R Y

35102 $ 3,387.67 $ 3,387.67 90 9% 84% 7% 0 2 1 2 1 0 R Y

35103 $ 4,042.31 $ 4,042.31 90 9% 84% 7% 0 2 1 2 1 0 R Y

35111 $ 2,375.67 $ 2,375.67 90 9% 84% 7% 0 2 1 2 1 0 R Y

35112 $ 3,409.81 $ 3,409.81 90 9% 84% 7% 0 2 1 2 1 0 R Y

35121 $ 2,971.49 $ 2,971.49 90 9% 84% 7% 0 2 1 2 0 0 R Y

35122 $ 3,897.47 $ 3,897.47 90 9% 84% 7% 0 2 1 2 1 0 R Y

35131 $ 2,501.54 $ 2,501.54 90 9% 84% 7% 0 2 1 2 1 0 R Y

35132 $ 2,934.17 $ 2,934.17 90 9% 84% 7% 0 2 1 2 1 0 R Y

35141 $ 1,991.74 $ 1,991.74 90 9% 84% 7% 0 2 1 2 1 0 R Y

35142 $ 2,382.63 $ 2,382.63 90 9% 84% 7% 0 2 1 2 1 0 R Y

35151 $ 2,233.99 $ 2,233.99 90 9% 84% 7% 0 2 1 2 1 0 R Y

35152 $ 2,493.95 $ 2,493.95 90 9% 84% 7% 0 2 1 2 1 0 R Y




35188 $ 1,933.55 $ 1,933.55 90 9% 84% 7% 0 2 0 2 1 0 R Y

35189 $ 2,865.23 $ 2,865.23 90 9% 84% 7% 0 2 0 2 1 0 R Y

35190 $ 1,374.42 $ 1,374.42 90 9% 84% 7% 0 2 0 2 1 0 R Y

35201 $ 1,706.49 $ 1,706.49 90 9% 84% 7% 0 2 1 2 1 0 R

35206 $ 1,404.78 $ 1,404.78 90 9% 84% 7% 0 2 1 2 1 0 R

35207 $ 1,378.22 $ 1,378.22 90 9% 84% 7% 0 2 1 1 1 0 R

35211 $ 2,477.50 $ 2,477.50 90 9% 84% 7% 0 2 1 2 1 0 R

35216 $ 3,677.36 $ 3,677.36 90 9% 84% 7% 0 2 1 2 1 0 R

35221 $ 2,626.14 $ 2,626.14 90 9% 84% 7% 0 2 1 2 1 0 R

35226 $ 1,502.82 $ 1,502.82 90 9% 84% 7% 0 2 1 2 1 0 R

35231 $ 2,251.70 $ 2,251.70 90 9% 84% 7% 0 2 1 2 1 0 R

35236 $ 1,774.80 $ 1,774.80 90 9% 84% 7% 0 2 1 2 1 0 R

35241 $ 2,502.80 $ 2,502.80 90 9% 84% 7% 0 2 1 2 1 0 R

35246 $ 2,822.85 $ 2,822.85 90 9% 84% 7% 0 2 1 2 1 0 R

35251 $ 3,077.11 $ 3,077.11 90 9% 84% 7% 0 2 1 2 1 0 R

35256 $ 1,835.52 $ 1,835.52 90 9% 84% 7% 0 2 1 2 1 0 R

35261 $ 1,919.01 $ 1,919.01 90 9% 84% 7% 0 2 1 2 1 0 R

35266 $ 1,564.17 $ 1,564.17 90 9% 84% 7% 0 2 1 2 1 0 R

35271 $ 2,488.26 $ 2,488.26 90 9% 84% 7% 0 2 1 2 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


35276 $ 2,629.30 $ 2,629.30 90 9% 84% 7% 0 2 1 2 1 0 R

35281 $ 2,907.60 $ 2,907.60 90 9% 84% 7% 0 2 1 2 1 0 R

35286 $ 1,683.08 $ 1,683.08 90 9% 84% 7% 0 2 1 2 1 0 R

35301 $ 2,039.81 $ 2,039.81 90 9% 84% 7% 0 2 1 2 1 0 R Y

35302 $ 2,025.27 $ 2,025.27 90 9% 84% 7% 0 2 1 2 1 0 R Y

35303 $ 2,233.36 $ 2,233.36 90 9% 84% 7% 0 2 1 2 1 0 R Y

35304 $ 2,317.48 $ 2,317.48 90 9% 84% 7% 0 2 1 2 1 0 R Y

35305 $ 2,215.65 $ 2,215.65 90 9% 84% 7% 0 2 1 2 1 0 R Y

35306 $ 795.05 $ 795.05 0 0% 0% 0% 0 0 0 2 1 0 R Y

35311 $ 2,805.14 $ 2,805.14 90 9% 84% 7% 0 2 1 2 1 0 R Y

35321 $ 1,605.29 $ 1,605.29 90 9% 84% 7% 0 2 1 2 1 0 R Y

35331 $ 2,613.49 $ 2,613.49 90 9% 84% 7% 0 2 1 2 1 0 R Y

35341 $ 2,465.49 $ 2,465.49 90 9% 84% 7% 0 2 1 2 1 0 R Y

35351 $ 2,301.04 $ 2,301.04 90 9% 84% 7% 0 2 1 2 1 0 R Y

35355 $ 1,860.82 $ 1,860.82 90 9% 84% 7% 0 2 1 2 1 0 R Y

35361 $ 2,733.03 $ 2,733.03 90 9% 84% 7% 0 2 1 2 1 0 R Y

35363 $ 3,181.48 $ 3,181.48 90 9% 84% 7% 0 2 1 2 1 0 R Y

35371 $ 1,476.89 $ 1,476.89 90 9% 84% 7% 0 2 1 2 1 0 R Y

35372 $ 1,767.84 $ 1,767.84 90 9% 84% 7% 0 2 1 2 1 0 R Y

35390 $ 286.52 $ 286.52 0 0% 0% 0% 0 0 0 2 1 0 R Y

35400 $ 266.92 $ 266.92 0 0% 0% 0% 0 0 0 0 1 0 R Y

35500 $ 571.78 $ 571.78 0 0% 0% 0% 0 0 0 2 1 0 R Y

35501 $ 2,696.35 $ 2,696.35 90 9% 84% 7% 0 2 1 2 1 0 R Y

35506 $ 2,288.39 $ 2,288.39 90 9% 84% 7% 0 2 1 2 1 0 R Y

35508 $ 2,400.34 $ 2,400.34 90 9% 84% 7% 0 2 1 2 1 0 R Y

35509 $ 2,530.63 $ 2,530.63 90 9% 84% 7% 0 2 1 2 1 0 R Y

35510 $ 2,203.63 $ 2,203.63 90 9% 84% 7% 0 2 1 2 1 0 R Y

35511 $ 2,196.67 $ 2,196.67 90 9% 84% 7% 0 2 1 2 1 0 R Y

35512 $ 2,488.89 $ 2,488.89 90 9% 84% 7% 0 2 1 2 1 0 R Y

35515 $ 2,670.42 $ 2,670.42 90 9% 84% 7% 0 2 1 2 1 0 R Y

35516 $ 2,184.02 $ 2,184.02 90 9% 84% 7% 0 2 1 2 1 0 R Y

35518 $ 2,082.19 $ 2,082.19 90 9% 84% 7% 0 2 1 2 1 0 R Y

35521 $ 2,197.31 $ 2,197.31 90 9% 84% 7% 0 2 1 2 1 0 R Y

35522 $ 2,178.33 $ 2,178.33 90 9% 84% 7% 0 2 1 2 1 0 R Y

35523 $ 2,308.63 $ 2,308.63 90 9% 84% 7% 0 2 1 2 1 0 R Y

35525 $ 2,070.81 $ 2,070.81 90 9% 84% 7% 0 2 1 2 1 0 R Y

35526 $ 3,034.74 $ 3,034.74 90 9% 84% 7% 0 2 1 2 1 0 R Y

35531 $ 3,647.63 $ 3,647.63 90 9% 84% 7% 0 2 1 2 1 0 R Y

35533 $ 2,686.86 $ 2,686.86 90 9% 84% 7% 0 2 1 2 1 0 R Y

35535 $ 3,433.84 $ 3,433.84 90 9% 84% 7% 0 2 1 2 1 0 R Y

35536 $ 3,124.55 $ 3,124.55 90 9% 84% 7% 0 2 1 2 1 0 R Y

35537 $ 4,305.43 $ 4,305.43 90 9% 84% 7% 0 2 0 2 1 0 R Y

35538 $ 4,212.45 $ 4,212.45 90 9% 84% 7% 0 2 0 2 1 0 R Y

35539 $ 3,986.02 $ 3,986.02 90 9% 84% 7% 0 2 1 2 1 0 R Y

35540 $ 4,612.19 $ 4,612.19 90 9% 84% 7% 0 2 1 1 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


35556 $ 2,523.04 $ 2,523.04 90 9% 84% 7% 0 2 1 2 1 0 R Y

35558 $ 2,225.14 $ 2,225.14 90 9% 84% 7% 0 2 1 2 1 0 R Y

35560 $ 3,061.30 $ 3,061.30 90 9% 84% 7% 0 2 1 2 1 0 R Y

35563 $ 2,719.75 $ 2,719.75 90 9% 84% 7% 0 2 1 2 1 0 R Y

35565 $ 2,400.34 $ 2,400.34 90 9% 84% 7% 0 2 1 2 1 0 R Y

35566 $ 3,008.17 $ 3,008.17 90 9% 84% 7% 0 2 1 2 1 0 R Y

35570 $ 2,720.38 $ 2,720.38 90 9% 84% 7% 0 2 1 2 1 0 R Y

35571 $ 2,390.85 $ 2,390.85 90 9% 84% 7% 0 2 1 2 1 0 R Y

35572 $ 620.48 $ 620.48 0 0% 0% 0% 0 0 0 2 0 0 R Y

35583 $ 2,608.43 $ 2,608.43 90 9% 84% 7% 0 2 1 2 1 0 R Y

35585 $ 3,022.09 $ 3,022.09 90 9% 84% 7% 0 2 1 2 1 0 R Y

35587 $ 2,467.38 $ 2,467.38 90 9% 84% 7% 0 2 1 2 1 0 R Y

35600 $ 456.03 $ 456.03 0 0% 0% 0% 0 0 0 2 1 0 R Y

35601 $ 2,522.41 $ 2,522.41 90 9% 84% 7% 0 2 1 2 1 0 R Y

35606 $ 2,115.08 $ 2,115.08 90 9% 84% 7% 0 2 1 2 1 0 R Y

35612 $ 1,914.58 $ 1,914.58 90 9% 84% 7% 0 2 1 2 1 0 R Y

35616 $ 1,984.79 $ 1,984.79 90 9% 84% 7% 0 2 1 2 1 0 R Y

35621 $ 1,980.36 $ 1,980.36 90 9% 84% 7% 0 2 1 2 1 0 R Y

35623 $ 2,375.04 $ 2,375.04 90 9% 84% 7% 0 2 1 2 1 0 R Y

35626 $ 2,836.76 $ 2,836.76 90 9% 84% 7% 0 2 1 2 1 0 R Y

35631 $ 3,332.01 $ 3,332.01 90 9% 84% 7% 0 2 1 2 1 0 R Y

35632 $ 3,233.97 $ 3,233.97 90 9% 84% 7% 0 2 1 2 1 0 R Y

35633 $ 3,603.99 $ 3,603.99 90 9% 84% 7% 0 2 1 2 1 0 R Y

35634 $ 3,240.93 $ 3,240.93 90 9% 84% 7% 0 2 1 2 1 0 R Y

35636 $ 2,913.93 $ 2,913.93 90 9% 84% 7% 0 2 1 2 1 0 R Y

35637 $ 3,127.71 $ 3,127.71 90 9% 84% 7% 0 2 0 2 1 0 R Y

35638 $ 3,178.31 $ 3,178.31 90 9% 84% 7% 0 2 0 2 1 0 R Y

35642 $ 1,986.05 $ 1,986.05 90 9% 84% 7% 0 2 1 2 1 0 R Y

35645 $ 1,885.48 $ 1,885.48 90 9% 84% 7% 0 2 1 2 1 0 R Y

35646 $ 3,092.93 $ 3,092.93 90 9% 84% 7% 0 2 0 2 1 0 R Y

35647 $ 2,801.98 $ 2,801.98 90 9% 84% 7% 0 2 1 2 1 0 R Y

35650 $ 1,965.18 $ 1,965.18 90 9% 84% 7% 0 2 1 2 1 0 R Y

35654 $ 2,469.91 $ 2,469.91 90 9% 84% 7% 0 2 0 2 1 0 R Y

35656 $ 1,955.69 $ 1,955.69 90 9% 84% 7% 0 2 1 2 1 0 R Y

35661 $ 1,960.75 $ 1,960.75 90 9% 84% 7% 0 2 1 2 1 0 R Y

35663 $ 2,253.60 $ 2,253.60 90 9% 84% 7% 0 2 1 2 1 0 R Y

35665 $ 2,115.08 $ 2,115.08 90 9% 84% 7% 0 2 1 2 1 0 R Y

35666 $ 2,283.96 $ 2,283.96 90 9% 84% 7% 0 2 1 2 1 0 R Y

35671 $ 2,015.15 $ 2,015.15 90 9% 84% 7% 0 2 1 2 1 0 R Y

35681 $ 144.21 $ 144.21 0 0% 0% 0% 0 0 0 2 1 0 R Y

35682 $ 633.77 $ 633.77 0 0% 0% 0% 0 0 0 0 1 0 R Y

35683 $ 731.17 $ 731.17 0 0% 0% 0% 0 0 0 0 1 0 R Y

35685 $ 356.10 $ 356.10 0 0% 0% 0% 0 0 0 2 1 0 R Y

35686 $ 286.52 $ 286.52 0 0% 0% 0% 0 0 0 2 1 0 R Y

35691 $ 1,691.31 $ 1,691.31 90 9% 84% 7% 0 2 1 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


35693 $ 1,511.68 $ 1,511.68 90 9% 84% 7% 0 2 1 2 1 0 R Y

35694 $ 1,774.16 $ 1,774.16 90 9% 84% 7% 0 2 1 2 1 0 R Y

35695 $ 1,873.47 $ 1,873.47 90 9% 84% 7% 0 2 1 2 1 0 R Y

35697 $ 264.39 $ 264.39 0 0% 0% 0% 0 0 0 2 2 0 R Y

35700 $ 273.87 $ 273.87 0 0% 0% 0% 0 0 0 2 1 0 R Y

35701 $ 1,032.87 $ 1,032.87 90 9% 84% 7% 0 2 1 2 1 0 R Y

35721 $ 831.11 $ 831.11 90 9% 84% 7% 0 2 1 2 1 0 R Y

35741 $ 929.78 $ 929.78 90 9% 84% 7% 0 2 1 2 1 0 R Y

35761 $ 713.46 $ 713.46 90 9% 84% 7% 0 2 1 2 1 0 R Y

35800 $ 1,300.42 $ 1,300.42 90 9% 84% 7% 0 2 0 2 1 0 R Y

35820 $ 3,603.35 $ 3,603.35 90 9% 84% 7% 0 2 0 2 1 0 R Y

35840 $ 2,144.18 $ 2,144.18 90 9% 84% 7% 0 2 0 2 1 0 R Y

35860 $ 1,514.84 $ 1,514.84 90 9% 84% 7% 0 2 0 2 1 0 R Y

35870 $ 2,234.62 $ 2,234.62 90 9% 84% 7% 0 2 0 2 1 0 R Y

35875 $ 1,076.52 $ 1,076.52 90 9% 84% 7% 0 2 0 1 1 0 R Y

35876 $ 1,708.38 $ 1,708.38 90 9% 84% 7% 0 2 0 2 1 0 R Y

35879 $ 1,663.48 $ 1,663.48 90 9% 84% 7% 0 2 1 2 1 0 R Y

35881 $ 1,839.31 $ 1,839.31 90 9% 84% 7% 0 2 1 2 1 0 R Y

35883 $ 2,175.80 $ 2,175.80 90 9% 84% 7% 0 2 1 2 1 0 R Y

35884 $ 2,220.08 $ 2,220.08 90 9% 84% 7% 0 2 1 2 1 0 R Y

35901 $ 898.78 $ 898.78 90 9% 84% 7% 0 2 0 2 1 0 R Y

35903 $ 1,022.12 $ 1,022.12 90 9% 84% 7% 0 2 0 2 1 0 R Y

35905 $ 3,188.43 $ 3,188.43 90 9% 84% 7% 0 2 0 2 1 0 R Y

35907 $ 3,435.74 $ 3,435.74 90 9% 84% 7% 0 2 0 2 1 0 R Y

36000 $ 47.44 $ 17.08 0 0% 0% 0% 9 9 9 9 9 9 R

36002 $ 294.75 $ 194.18 0 0% 0% 0% 0 2 1 1 0 0 R

36005 $ 604.04 $ 87.29 0 0% 0% 0% 0 2 1 0 0 0 R

36010 $ 899.42 $ 197.97 0 0% 0% 0% 0 2 1 1 0 0 R

36011 $ 1,543.93 $ 284.63 0 0% 0% 0% 0 2 1 1 0 0 R

36012 $ 1,590.11 $ 314.99 0 0% 0% 0% 0 2 1 1 0 0 R

36013 $ 1,440.20 $ 223.91 0 0% 0% 0% 0 2 0 1 0 0 R

36014 $ 1,490.17 $ 274.51 0 0% 0% 0% 0 2 1 1 0 0 R

36015 $ 1,609.08 $ 313.09 0 0% 0% 0% 0 2 1 1 0 0 R

36100 $ 881.07 $ 274.51 0 0% 0% 0% 0 2 1 1 0 0 R

36120 $ 779.24 $ 181.53 0 0% 0% 0% 0 2 0 1 0 0 R

36140 $ 786.20 $ 162.55 0 0% 0% 0% 0 2 0 1 0 0 R

36147 $ 1,532.88 $ 336.29 0 0% 0% 0% 0 2 0 2 0 0 F Y

36148 $ 480.92 $ 86.37 0 0% 0% 0% 0 0 0 2 0 0 F Y

36160 $ 914.60 $ 225.80 0 0% 0% 0% 0 2 0 1 0 0 R

36200 $ 1,040.46 $ 251.10 0 0% 0% 0% 0 2 1 1 0 0 R

36215 $ 2,093.58 $ 425.04 0 0% 0% 0% 0 2 0 1 0 0 R

36216 $ 2,156.83 $ 488.92 0 0% 0% 0% 0 2 0 1 0 0 R

36217 $ 3,547.06 $ 581.90 0 0% 0% 0% 0 2 0 1 0 0 R

36218 $ 344.08 $ 93.61 0 0% 0% 0% 0 0 0 1 0 0 R

36221 $ 1,917.74 $ 362.42 0 0% 0% 0% 0 2 2 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


36222 $ 2,234.62 $ 506.00 0 0% 0% 0% 0 2 1 1 0 0 R

36223 $ 2,747.58 $ 559.76 0 0% 0% 0% 0 2 1 1 0 0 R

36224 $ 3,504.05 $ 634.40 0 0% 0% 0% 0 2 1 1 0 0 R

36225 $ 2,640.69 $ 555.97 0 0% 0% 0% 0 2 1 1 0 0 R

36226 $ 3,321.89 $ 626.81 0 0% 0% 0% 0 2 1 1 0 0 R

36227 $ 462.36 $ 208.09 0 0% 0% 0% 0 0 1 1 0 0 R

36228 $ 2,380.10 $ 425.67 0 0% 0% 0% 0 0 1 1 0 0 R

36245 $ 2,428.80 $ 433.90 0 0% 0% 0% 0 2 1 1 0 0 R

36246 $ 1,519.27 $ 460.46 0 0% 0% 0% 0 2 1 1 0 0 R

36247 $ 2,788.69 $ 550.28 0 0% 0% 0% 0 2 1 1 0 0 R

36248 $ 283.36 $ 89.82 0 0% 0% 0% 0 0 0 1 0 0 R

36251 $ 2,557.83 $ 479.44 0 0% 0% 0% 0 2 0 1 0 0 R

36252 $ 2,757.70 $ 650.21 0 0% 0% 0% 0 2 2 1 0 0 R

36253 $ 4,122.64 $ 662.86 0 0% 0% 0% 0 2 0 1 0 0 R

36254 $ 3,981.59 $ 759.00 0 0% 0% 0% 0 2 2 1 0 0 R








36410 $ 30.99 $ 17.08 0 0% 0% 0% 0 2 0 1 0 0 R

36415 $ 4.20 $ 4.20 0 0% 0% 0% 9 9 9 9 9 9 L

36416 $ 4.20 $ 4.20 0 0% 0% 0% 9 9 9 9 9 9 L


36425 $ 72.74 $ 72.74 0 0% 0% 0% 0 2 0 1 0 0 R

36430 $ 65.78 $ 65.78 0 0% 0% 0% 5 0 0 1 0 0 R





36460 $ 626.81 $ 626.81 0 0% 0% 0% 0 2 0 2 0 0 R Y




36473 $ 2,805.14 $ 311.19 0 0% 0% 0% 0 2 0 1 0 0 R Y

36474 $ 506.63 $ 155.60 0 0% 0% 0% 0 0 1 1 0 0 R Y

36475 $ 2,831.70 $ 504.10 0 0% 0% 0% 0 2 1 1 0 0 R Y

36476 $ 538.89 $ 244.15 0 0% 0% 0% 0 0 1 1 0 0 R Y

36478 $ 2,234.62 $ 502.21 0 0% 0% 0% 0 2 1 1 0 0 R Y

36479 $ 567.99 $ 246.68 0 0% 0% 0% 0 0 1 1 0 0 R Y

36481 $ 3,671.66 $ 616.69 0 0% 0% 0% 0 2 0 1 0 0 R

36500 $ 329.53 $ 329.53 0 0% 0% 0% 0 2 0 1 0 0 R




Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY










36556 $ 428.84 $ 218.21 0 0% 0% 0% 0 0 0 1 0 0 R


36558 $ 1,329.52 $ 481.33 10 10% 80% 10% 0 2 1 0 0 0 R


36561 $ 2,022.74 $ 617.32 10 10% 80% 10% 0 2 1 0 0 0 R

36563 $ 2,281.43 $ 664.13 10 10% 80% 10% 0 2 0 0 0 0 R

36565 $ 1,633.75 $ 601.51 10 10% 80% 10% 0 2 1 0 0 0 R

36566 $ 10,183.88 $ 674.88 10 10% 80% 10% 0 2 1 0 0 0 R


36569 $ 464.26 $ 167.61 0 0% 0% 0% 0 0 0 1 0 0 R


36571 $ 2,262.45 $ 561.66 10 10% 80% 10% 0 2 1 0 0 0 R

36575 $ 309.93 $ 63.25 0 0% 0% 0% 0 2 0 0 0 0 R

36576 $ 576.21 $ 334.59 10 10% 80% 10% 0 2 0 0 0 0 R

36578 $ 828.58 $ 370.65 10 10% 80% 10% 0 2 0 0 0 0 R

36580 $ 397.21 $ 121.44 0 0% 0% 0% 0 0 0 1 0 0 R

36581 $ 1,314.34 $ 335.86 10 10% 80% 10% 0 2 0 0 0 0 R

36582 $ 1,876.00 $ 530.04 10 10% 80% 10% 0 2 0 0 0 0 R

36583 $ 2,321.91 $ 583.80 10 10% 80% 10% 0 2 0 0 0 0 R

36584 $ 381.40 $ 122.07 0 0% 0% 0% 0 0 0 1 0 0 R

36585 $ 2,005.66 $ 497.15 10 10% 80% 10% 0 2 0 0 0 0 R

36589 $ 298.54 $ 250.47 10 10% 80% 10% 0 2 0 0 0 0 R

36590 $ 401.64 $ 347.24 10 10% 80% 10% 0 2 0 0 0 0 R

36591 $ 44.28 $ 44.28 0 0% 0% 0% 3 0 0 0 0 0 R

36592 $ 49.97 $ 49.97 0 0% 0% 0% 3 0 0 0 0 0 R

36593 $ 58.82 $ 58.82 0 0% 0% 0% 3 0 0 0 0 0 R

36595 $ 1,089.17 $ 335.86 0 0% 0% 0% 0 2 0 1 0 0 R

36596 $ 245.41 $ 81.59 0 0% 0% 0% 0 2 0 1 0 0 R

36597 $ 234.66 $ 111.95 0 0% 0% 0% 0 2 0 1 0 0 R

36598 $ 206.20 $ 67.68 0 0% 0% 0% 9 2 1 0 0 0 R

36600 $ 58.19 $ 27.83 0 0% 0% 0% 0 2 0 1 0 0 R

36620 $ 92.35 $ 92.35 0 0% 0% 0% 0 0 0 1 0 0 R

36625 $ 187.22 $ 187.22 0 0% 0% 0% 0 0 0 1 0 0 R




36800 $ 223.27 $ 223.27 0 0% 0% 0% 0 2 0 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


36810 $ 390.25 $ 390.25 0 0% 0% 0% 0 2 0 1 0 0 R

36815 $ 245.41 $ 245.41 0 0% 0% 0% 0 2 0 1 0 0 R

36818 $ 1,253.62 $ 1,253.62 90 9% 84% 7% 0 2 0 2 1 0 R Y

36819 $ 1,322.56 $ 1,322.56 90 9% 84% 7% 0 2 0 2 1 0 R Y

36820 $ 1,323.19 $ 1,323.19 90 9% 84% 7% 0 2 1 2 1 0 R Y

36821 $ 1,199.85 $ 1,199.85 90 9% 84% 7% 0 2 0 2 1 0 R Y


36825 $ 1,444.00 $ 1,444.00 90 9% 84% 7% 0 2 0 2 1 0 R Y

36830 $ 1,206.18 $ 1,206.18 90 9% 84% 7% 0 2 0 2 1 0 R Y

36831 $ 1,115.10 $ 1,115.10 90 9% 84% 7% 0 2 0 2 1 0 R Y

36832 $ 1,368.10 $ 1,368.10 90 9% 84% 7% 0 2 0 2 1 0 R

36833 $ 1,468.03 $ 1,468.03 90 9% 84% 7% 0 2 0 2 1 0 R Y


36838 $ 2,061.32 $ 2,061.32 90 9% 84% 7% 0 2 1 2 1 0 R Y

36860 $ 386.46 $ 203.67 0 0% 0% 0% 0 2 0 1 0 0 R

36861 $ 240.35 $ 240.35 0 0% 0% 0% 0 2 0 1 0 0 R

36901 $ 1,060.07 $ 261.86 0 0% 0% 0% 0 2 0 1 0 0 R Y

36902 $ 2,265.62 $ 389.62 0 0% 0% 0% 0 2 0 1 0 0 R Y

36903 $ 10,481.16 $ 533.20 0 0% 0% 0% 0 2 0 1 0 0 R Y

36904 $ 3,299.75 $ 614.16 0 0% 0% 0% 0 2 0 1 1 0 R Y

36905 $ 4,223.84 $ 770.39 0 0% 0% 0% 0 2 0 1 1 0 R Y

36906 $ 12,690.48 $ 898.78 0 0% 0% 0% 0 2 0 1 1 0 R Y

36907 $ 1,356.08 $ 223.91 0 0% 0% 0% 0 0 0 1 0 0 R Y

36908 $ 5,030.91 $ 335.86 0 0% 0% 0% 0 0 0 1 0 0 R Y

36909 $ 3,664.71 $ 319.41 0 0% 0% 0% 0 0 0 1 0 0 R Y

37140 $ 4,146.67 $ 4,146.67 90 9% 84% 7% 0 2 0 1 1 0 R Y

37145 $ 3,849.40 $ 3,849.40 90 9% 84% 7% 0 2 0 2 0 0 R Y

37160 $ 3,955.02 $ 3,955.02 90 9% 84% 7% 0 2 0 2 1 0 R Y

37180 $ 3,805.75 $ 3,805.75 90 9% 84% 7% 0 2 0 2 1 0 R Y

37181 $ 3,908.22 $ 3,908.22 90 9% 84% 7% 0 2 0 2 1 0 R Y

37182 $ 1,523.06 $ 1,523.06 0 0% 0% 0% 0 2 0 0 0 0 R Y

37183 $ 10,937.19 $ 696.38 0 0% 0% 0% 0 2 0 0 0 0 R Y

37184 $ 4,134.02 $ 812.76 0 0% 0% 0% 0 2 1 1 2 0 R

37185 $ 1,308.01 $ 302.97 0 0% 0% 0% 0 0 2 1 2 0 R

37186 $ 2,488.26 $ 445.28 0 0% 0% 0% 0 0 2 1 2 0 R

37187 $ 3,671.66 $ 714.09 0 0% 0% 0% 0 2 1 1 2 0 R

37188 $ 3,143.53 $ 509.16 0 0% 0% 0% 0 2 1 1 2 0 R

37191 $ 4,818.39 $ 411.13 0 0% 0% 0% 0 2 0 1 0 0 R Y

37192 $ 2,987.30 $ 667.92 0 0% 0% 0% 0 2 0 1 0 0 R Y

37193 $ 2,845.62 $ 640.72 0 0% 0% 0% 0 2 0 1 0 0 R Y


37197 $ 2,684.33 $ 548.38 0 0% 0% 0% 0 2 0 1 0 0 R

37200 $ 402.27 $ 402.27 0 0% 0% 0% 0 2 0 1 0 0 R Y

37211 $ 698.28 $ 698.28 0 0% 0% 0% 0 2 1 1 0 0 R

37212 $ 610.36 $ 610.36 0 0% 0% 0% 0 2 1 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


37213 $ 426.31 $ 426.31 0 0% 0% 0% 0 2 0 1 0 0 R

37214 $ 223.91 $ 223.91 0 0% 0% 0% 0 2 0 1 0 0 R

37215 $ 1,794.40 $ 1,794.40 90 9% 84% 7% 0 2 1 0 0 0 R Y


37217 $ 1,980.36 $ 1,980.36 90 9% 84% 7% 0 2 1 0 0 0 R

37218 $ 1,469.93 $ 1,469.93 90 9% 84% 7% 0 2 1 0 0 0 R Y

37220 $ 5,722.86 $ 724.21 0 0% 0% 0% 0 2 1 1 0 0 R Y

37221 $ 8,501.43 $ 895.62 0 0% 0% 0% 0 2 1 0 0 0 R Y

37222 $ 1,594.53 $ 336.49 0 0% 0% 0% 0 0 1 0 0 0 R Y

37223 $ 4,779.17 $ 385.83 0 0% 0% 0% 0 0 1 0 0 0 R Y

37224 $ 6,949.28 $ 802.01 0 0% 0% 0% 0 2 1 0 0 0 R Y

37225 $ 20,458.85 $ 1,093.59 0 0% 0% 0% 0 2 1 0 0 0 R Y

37226 $ 16,759.99 $ 944.32 0 0% 0% 0% 0 2 1 0 0 0 R Y

37227 $ 27,728.17 $ 1,318.13 0 0% 0% 0% 0 2 1 0 0 0 R Y

37228 $ 9,965.04 $ 982.27 0 0% 0% 0% 0 2 1 0 0 0 R Y

37229 $ 20,151.45 $ 1,279.55 0 0% 0% 0% 0 2 1 0 0 0 R Y

37230 $ 15,372.91 $ 1,263.10 0 0% 0% 0% 0 2 1 0 0 0 R Y

37231 $ 24,950.23 $ 1,371.89 0 0% 0% 0% 0 2 1 0 0 0 R Y

37232 $ 2,211.22 $ 365.59 0 0% 0% 0% 0 0 1 0 0 0 R Y

37233 $ 2,660.30 $ 593.92 0 0% 0% 0% 0 0 1 0 0 0 R Y

37234 $ 7,292.09 $ 514.86 0 0% 0% 0% 0 0 1 0 0 0 R Y

37235 $ 7,820.86 $ 714.09 0 0% 0% 0% 0 0 1 0 0 0 R Y

37236 $ 7,401.52 $ 800.11 0 0% 0% 0% 0 2 1 0 0 0 R

37237 $ 4,527.44 $ 384.56 0 0% 0% 0% 0 0 1 0 0 0 R

37238 $ 7,744.96 $ 545.85 0 0% 0% 0% 0 2 1 0 0 0 R

37239 $ 3,758.32 $ 272.61 0 0% 0% 0% 0 0 1 0 0 0 R

37241 $ 8,891.05 $ 803.91 0 0% 0% 0% 0 2 0 1 0 0 R

37242 $ 13,974.46 $ 878.54 0 0% 0% 0% 0 2 0 1 0 0 R

37243 $ 18,174.89 $ 1,045.52 0 0% 0% 0% 0 2 0 1 0 0 R

37244 $ 12,646.84 $ 1,230.21 0 0% 0% 0% 0 2 0 1 0 0 R

37246 $ 3,992.34 $ 638.19 0 0% 0% 0% 0 2 1 1 0 0 R UR

37247 $ 1,610.98 $ 316.25 0 0% 0% 0% 0 0 1 1 0 0 R UR

37248 $ 2,757.70 $ 549.01 0 0% 0% 0% 0 2 1 1 0 0 R UR

37249 $ 1,178.98 $ 269.45 0 0% 0% 0% 0 0 1 1 0 0 R UR

37252 $ 2,588.82 $ 165.08 0 0% 0% 0% 0 0 0 0 1 0 R

37253 $ 380.13 $ 132.83 0 0% 0% 0% 0 0 0 0 1 0 R

37500 $ 1,163.17 $ 1,163.17 90 9% 84% 7% 0 2 1 1 1 0 R Y


37565 $ 1,346.59 $ 1,346.59 90 9% 84% 7% 0 2 1 0 1 0 R

37600 $ 1,288.40 $ 1,288.40 90 9% 84% 7% 0 2 0 2 1 0 R

37605 $ 1,418.07 $ 1,418.07 90 9% 84% 7% 0 2 0 2 1 0 R

37606 $ 932.94 $ 932.94 90 9% 84% 7% 0 2 0 2 0 0 R

37607 $ 679.94 $ 679.94 90 9% 84% 7% 0 2 0 1 1 0 R

37609 $ 566.72 $ 376.34 10 10% 80% 10% 0 2 1 1 0 0 R

37615 $ 931.04 $ 931.04 90 9% 84% 7% 0 2 0 2 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


37616 $ 1,980.99 $ 1,980.99 90 9% 84% 7% 0 2 0 2 1 0 R

37617 $ 2,410.46 $ 2,410.46 90 9% 84% 7% 0 2 0 2 1 0 R

37618 $ 694.49 $ 694.49 90 9% 84% 7% 0 2 0 2 1 0 R

37619 $ 2,954.41 $ 2,954.41 90 9% 84% 7% 0 2 0 2 0 0 R Y

37650 $ 833.00 $ 833.00 90 9% 84% 7% 0 2 1 1 1 0 R Y

37660 $ 2,335.19 $ 2,335.19 90 9% 84% 7% 0 2 1 2 1 0 R Y

37700 $ 450.97 $ 450.97 90 9% 84% 7% 0 2 1 1 0 0 R Y



37735 $ 1,047.42 $ 1,047.42 90 9% 84% 7% 0 2 1 1 1 0 R Y

37760 $ 1,106.24 $ 1,106.24 90 9% 84% 7% 0 2 1 1 1 0 R Y

37761 $ 994.29 $ 994.29 90 9% 84% 7% 0 2 1 2 1 0 R Y

37765 $ 1,187.20 $ 814.66 90 9% 84% 7% 0 2 1 1 1 0 R Y

37766 $ 1,406.05 $ 992.39 90 9% 84% 7% 0 2 1 1 1 0 R Y

37780 $ 455.40 $ 455.40 90 9% 84% 7% 0 2 1 1 1 0 R Y

37785 $ 648.31 $ 476.91 90 9% 84% 7% 0 2 1 1 0 0 R Y




38100 $ 2,068.91 $ 2,068.91 90 11% 73% 16% 0 2 0 2 1 0 R

38101 $ 2,072.70 $ 2,072.70 90 11% 73% 16% 0 2 0 2 1 0 R

38102 $ 469.32 $ 469.32 0 0% 0% 0% 0 0 0 2 1 0 R

38115 $ 2,278.27 $ 2,278.27 90 11% 73% 16% 0 2 0 2 1 0 R

38120 $ 1,891.18 $ 1,891.18 90 9% 84% 7% 0 2 0 2 1 0 R


38200 $ 248.57 $ 248.57 0 0% 0% 0% 0 2 0 0 0 0 R













38220 $ 311.19 $ 111.95 0 0% 0% 0% 0 2 1 0 0 0 R

38221 $ 311.82 $ 137.25 0 0% 0% 0% 0 2 1 0 0 0 R

38230 $ 363.06 $ 363.06 0 0% 0% 0% 0 2 0 0 0 0 R







Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


38243 $ 218.85 $ 218.85 0 0% 0% 0% 0 2 0 0 0 0 R

38300 $ 498.41 $ 331.43 10 10% 80% 10% 0 2 0 1 0 0 R

38305 $ 831.11 $ 831.11 90 11% 73% 16% 0 2 0 1 0 0 R


38380 $ 1,020.22 $ 1,020.22 90 11% 73% 16% 0 2 0 2 1 0 R Y

38381 $ 1,443.37 $ 1,443.37 90 11% 73% 16% 0 2 0 2 1 0 R Y

38382 $ 1,208.71 $ 1,208.71 90 11% 73% 16% 0 2 0 2 1 0 R Y

38500 $ 602.14 $ 458.56 10 10% 80% 10% 0 2 1 1 0 0 R

38505 $ 233.39 $ 131.56 0 0% 0% 0% 0 2 1 1 0 0 R

38510 $ 942.43 $ 759.00 10 10% 80% 10% 0 2 1 1 0 0 R

38520 $ 838.06 $ 838.06 90 11% 73% 16% 0 2 1 1 0 0 R

38525 $ 787.46 $ 787.46 90 11% 73% 16% 0 2 1 1 0 0 R

38530 $ 1,000.62 $ 1,000.62 90 11% 73% 16% 0 2 1 2 1 0 R

38542 $ 941.79 $ 941.79 90 11% 73% 16% 0 2 1 2 1 0 R

38550 $ 913.33 $ 913.33 90 11% 73% 16% 0 2 0 0 0 0 R

38555 $ 1,825.40 $ 1,825.40 90 11% 73% 16% 0 2 0 2 1 0 R



38570 $ 915.23 $ 915.23 10 10% 80% 10% 0 3 0 2 2 0 49320 R Y

38571 $ 1,218.83 $ 1,218.83 10 10% 80% 10% 0 2 2 2 2 0 49320 R Y

38572 $ 1,693.84 $ 1,693.84 10 10% 80% 10% 0 2 2 2 2 0 49320 R Y


38700 $ 1,464.24 $ 1,464.24 90 11% 73% 16% 0 2 1 2 1 0 R Y

38720 $ 2,433.23 $ 2,433.23 90 11% 73% 16% 0 2 1 2 1 0 R Y

38724 $ 2,636.26 $ 2,636.26 90 11% 73% 16% 0 2 1 2 1 0 R Y

38740 $ 1,249.19 $ 1,249.19 90 11% 73% 16% 0 2 1 2 1 0 R Y

38745 $ 1,576.19 $ 1,576.19 90 11% 73% 16% 0 2 1 2 1 0 R Y

38746 $ 383.30 $ 383.30 0 0% 0% 0% 0 0 0 2 1 0 R Y

38747 $ 476.91 $ 476.91 0 0% 0% 0% 0 0 0 2 1 0 R Y

38760 $ 1,518.63 $ 1,518.63 90 11% 73% 16% 0 2 1 2 1 0 R Y

38765 $ 2,328.87 $ 2,328.87 90 11% 73% 16% 0 2 1 2 1 0 R Y

38770 $ 1,469.93 $ 1,469.93 90 11% 73% 16% 0 2 1 2 1 0 R Y

38780 $ 1,864.61 $ 1,864.61 90 11% 73% 16% 0 2 0 2 1 0 R Y

38790 $ 151.17 $ 151.17 0 0% 0% 0% 0 2 1 1 0 0 R Y

38792 $ 73.37 $ 73.37 0 0% 0% 0% 0 2 1 1 0 0 R Y




39000 $ 896.89 $ 896.89 90 9% 84% 7% 0 2 0 2 1 0 R

39010 $ 1,413.64 $ 1,413.64 90 9% 84% 7% 0 2 0 2 1 0 R

39200 $ 1,561.64 $ 1,561.64 90 9% 84% 7% 0 2 0 2 1 0 R Y

39220 $ 2,036.02 $ 2,036.02 90 9% 84% 7% 0 2 0 2 1 0 R Y

39401 $ 556.60 $ 556.60 0 0% 0% 0% 0 2 0 1 0 0 R Y

39402 $ 725.48 $ 725.48 0 0% 0% 0% 0 2 0 1 0 0 R Y




Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


39501 $ 1,526.22 $ 1,526.22 90 9% 84% 7% 0 2 0 2 1 0 R


39540 $ 1,558.48 $ 1,558.48 90 9% 84% 7% 0 2 0 2 1 0 R

39541 $ 1,692.57 $ 1,692.57 90 9% 84% 7% 0 2 0 2 1 0 R

39545 $ 1,592.64 $ 1,592.64 90 9% 84% 7% 0 2 0 2 1 0 R

39560 $ 1,435.78 $ 1,435.78 90 9% 84% 7% 0 2 0 2 1 0 R

39561 $ 2,235.89 $ 2,235.89 90 9% 84% 7% 0 2 0 2 1 0 R




40510 $ 895.62 $ 655.90 90 9% 81% 10% 0 2 0 1 0 0 R Y

40520 $ 905.74 $ 659.70 90 9% 81% 10% 0 2 0 1 0 0 R Y

40525 $ 1,012.00 $ 1,012.00 90 9% 81% 10% 0 2 0 1 0 0 R Y

40527 $ 1,142.93 $ 1,142.93 90 9% 81% 10% 0 2 0 0 0 0 R Y

40530 $ 991.13 $ 738.13 90 9% 81% 10% 0 2 0 1 0 0 R Y

40650 $ 814.66 $ 551.54 90 9% 81% 10% 0 2 0 0 0 0 R

40652 $ 912.07 $ 653.37 90 9% 81% 10% 0 2 0 0 0 0 R

40654 $ 1,059.44 $ 786.83 90 9% 81% 10% 0 2 0 1 0 0 R







40800 $ 402.27 $ 248.57 10 10% 80% 10% 0 2 0 1 0 0 R

40801 $ 590.76 $ 416.19 10 10% 80% 10% 0 2 0 1 0 0 R

40804 $ 345.98 $ 212.52 10 10% 80% 10% 0 2 0 0 0 0 R

40805 $ 603.41 $ 435.16 10 10% 80% 10% 0 2 0 0 0 0 R

40806 $ 199.24 $ 61.99 0 0% 0% 0% 0 2 0 0 0 0 R







40819 $ 595.18 $ 451.61 90 9% 81% 10% 0 2 0 0 0 0 R Y

40820 $ 504.10 $ 327.64 10 10% 80% 10% 0 2 0 1 0 0 R

40830 $ 506.00 $ 312.46 10 10% 80% 10% 0 2 0 0 0 0 R

40831 $ 635.66 $ 421.88 10 10% 80% 10% 0 2 0 0 0 0 R

40840 $ 1,499.03 $ 1,154.31 90 9% 81% 10% 0 2 0 2 0 0 R Y

40842 $ 1,514.21 $ 1,197.32 90 9% 81% 10% 0 2 0 0 0 0 R Y

40843 $ 2,006.29 $ 1,571.13 90 9% 81% 10% 0 2 2 2 0 0 R Y

40844 $ 2,379.47 $ 1,923.43 90 9% 81% 10% 0 2 0 2 0 0 R Y

40845 $ 2,686.86 $ 2,245.38 90 9% 81% 10% 0 2 0 0 0 0 R Y




Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


41000 $ 304.23 $ 209.36 10 10% 80% 10% 0 2 0 1 0 0 R

41005 $ 428.84 $ 234.03 10 10% 80% 10% 0 2 0 0 0 0 R

41006 $ 725.48 $ 503.47 90 9% 81% 10% 0 2 0 0 0 0 R

41007 $ 715.99 $ 488.92 90 9% 81% 10% 0 2 0 0 0 0 R

41008 $ 713.46 $ 504.74 90 9% 81% 10% 0 2 0 0 0 0 R

41009 $ 757.10 $ 549.01 90 9% 81% 10% 0 2 0 0 0 0 R

41010 $ 377.60 $ 200.50 10 10% 80% 10% 0 2 0 0 0 0 R

41015 $ 853.24 $ 657.17 90 9% 81% 10% 0 2 0 0 0 0 R

41016 $ 827.31 $ 659.07 90 9% 81% 10% 0 2 0 0 0 0 R

41017 $ 837.43 $ 663.49 90 9% 81% 10% 0 2 0 0 0 0 R

41018 $ 946.85 $ 771.65 90 9% 81% 10% 0 2 0 0 0 0 R


41100 $ 314.35 $ 199.87 10 10% 80% 10% 0 2 0 1 0 0 R Y

41105 $ 320.05 $ 208.09 10 10% 80% 10% 0 2 0 1 0 0 R Y

41108 $ 278.30 $ 168.88 10 10% 80% 10% 0 2 0 1 0 0 R Y





41115 $ 462.36 $ 269.45 10 10% 80% 10% 0 2 0 0 0 0 R










41250 $ 502.21 $ 285.26 10 10% 80% 10% 0 2 0 0 0 0 R

41251 $ 536.99 $ 336.49 10 10% 80% 10% 0 2 0 0 0 0 R

41252 $ 591.39 $ 390.25 10 10% 80% 10% 0 2 0 0 0 0 R

41500 $ 845.02 $ 845.02 90 9% 81% 10% 0 2 0 0 0 0 R


41512 $ 1,235.91 $ 1,235.91 90 10% 76% 14% 0 2 0 0 0 0 R Y

41520 $ 662.23 $ 481.97 90 9% 81% 10% 0 2 0 0 0 0 R Y

41530 $ 1,852.59 $ 703.97 10 10% 80% 10% 0 2 0 0 0 0 R Y


41800 $ 524.34 $ 279.57 10 10% 80% 10% 0 2 0 1 0 0 R

41805 $ 467.42 $ 322.58 10 10% 80% 10% 0 2 0 0 0 0 R

41806 $ 666.02 $ 487.03 10 10% 80% 10% 0 2 0 0 0 0 R







Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY







41850 $ 67.44 $ 67.44 0 0% 0% 0% 0 2 0 0 0 0 F Y

41870 $ 579.90 $ 579.90 0 0% 0% 0% 0 2 0 0 0 0 F Y

41872 $ 709.03 $ 493.98 90 9% 81% 10% 0 2 0 0 0 0 R Y

41874 $ 714.73 $ 481.97 90 9% 81% 10% 0 2 0 0 0 0 R Y


42000 $ 299.17 $ 194.18 10 10% 80% 10% 0 2 0 0 0 0 R






42140 $ 473.11 $ 287.16 90 9% 81% 10% 0 2 0 1 0 0 R Y

42145 $ 1,294.10 $ 1,294.10 90 9% 81% 10% 0 2 0 1 0 0 R Y


42180 $ 451.61 $ 337.76 10 10% 80% 10% 0 2 0 0 0 0 R

42182 $ 590.76 $ 469.32 10 10% 80% 10% 0 2 0 0 0 0 R







42226 $ 1,674.86 $ 1,674.86 90 9% 81% 10% 0 2 0 2 0 0 R Y

42227 $ 1,581.25 $ 1,581.25 90 9% 81% 10% 0 2 0 2 0 0 R Y

42235 $ 1,356.08 $ 1,356.08 90 9% 81% 10% 0 2 0 2 0 0 R

42260 $ 1,550.89 $ 1,280.81 90 9% 81% 10% 0 2 0 2 0 0 R

42280 $ 305.50 $ 204.30 10 10% 80% 10% 0 2 0 0 0 0 R

42281 $ 380.13 $ 278.30 10 10% 80% 10% 0 2 0 0 0 0 R


42300 $ 388.36 $ 281.46 10 10% 80% 10% 0 2 0 1 0 0 R

42305 $ 792.52 $ 792.52 90 9% 81% 10% 0 2 0 0 0 0 R

42310 $ 298.54 $ 228.97 10 10% 80% 10% 0 2 0 0 0 0 R

42320 $ 460.46 $ 321.31 10 10% 80% 10% 0 2 0 0 0 0 R




42400 $ 196.71 $ 101.83 0 0% 0% 0% 0 2 0 1 0 0 R Y

42405 $ 551.54 $ 414.92 10 10% 80% 10% 0 2 0 1 0 0 R Y

42408 $ 841.86 $ 601.51 90 9% 81% 10% 0 2 0 0 0 0 R

42409 $ 620.48 $ 409.86 90 9% 81% 10% 0 2 0 2 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY







42440 $ 752.68 $ 752.68 90 9% 81% 10% 0 2 1 2 1 0 R

42450 $ 839.33 $ 661.60 90 9% 81% 10% 0 2 0 0 0 0 R

42500 $ 805.17 $ 631.87 90 9% 81% 10% 0 2 0 0 0 0 R

42505 $ 1,025.92 $ 832.37 90 9% 81% 10% 0 2 0 1 0 0 R

42507 $ 927.25 $ 927.25 90 9% 81% 10% 0 2 2 2 0 0 R

42509 $ 1,550.89 $ 1,550.89 90 9% 81% 10% 0 2 2 0 0 0 R

42510 $ 1,189.10 $ 1,189.10 90 9% 81% 10% 0 2 2 2 1 0 R

42550 $ 251.74 $ 115.75 0 0% 0% 0% 0 2 0 1 0 0 R

42600 $ 874.12 $ 631.24 90 9% 81% 10% 0 2 0 0 0 0 R

42650 $ 154.96 $ 108.79 0 0% 0% 0% 0 2 0 1 0 0 R

42660 $ 235.92 $ 162.55 0 0% 0% 0% 0 2 0 0 0 0 R



42700 $ 352.30 $ 250.47 10 10% 80% 10% 0 2 0 1 0 0 R

42720 $ 831.11 $ 714.73 10 10% 80% 10% 0 2 0 0 0 0 R

42725 $ 1,499.03 $ 1,499.03 90 9% 81% 10% 0 2 0 2 1 0 R

42800 $ 294.11 $ 206.20 10 10% 80% 10% 0 2 0 1 0 0 R Y

42804 $ 365.59 $ 209.36 10 10% 80% 10% 0 2 0 1 0 0 R Y

42806 $ 409.23 $ 242.88 10 10% 80% 10% 0 2 0 1 0 0 R Y

42808 $ 419.98 $ 297.28 10 10% 80% 10% 0 2 0 1 0 0 R Y

42809 $ 372.54 $ 223.91 10 10% 80% 10% 0 2 0 1 0 0 R

42810 $ 719.79 $ 534.46 90 9% 81% 10% 0 2 1 2 0 0 R Y

42815 $ 1,029.08 $ 1,029.08 90 9% 81% 10% 0 2 1 2 1 0 R Y


42821 $ 551.54 $ 551.54 90 9% 81% 10% 0 2 0 0 0 0 R Y


42826 $ 461.73 $ 461.73 90 9% 81% 10% 0 2 0 1 0 0 R Y









42870 $ 1,120.16 $ 1,120.16 90 9% 81% 10% 0 2 0 0 0 0 R




42900 $ 618.59 $ 618.59 10 10% 80% 10% 0 2 0 0 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


42950 $ 1,533.18 $ 1,533.18 90 9% 81% 10% 0 2 0 2 1 0 R

42953 $ 1,843.11 $ 1,843.11 90 9% 81% 10% 0 2 0 2 0 0 R

42955 $ 1,425.66 $ 1,425.66 90 9% 81% 10% 0 2 0 2 0 0 R

42960 $ 312.46 $ 312.46 10 10% 80% 10% 0 2 0 0 0 0 R

42961 $ 776.71 $ 776.71 90 9% 81% 10% 0 2 0 2 0 0 R

42962 $ 953.81 $ 953.81 90 9% 81% 10% 0 2 0 1 0 0 R

42970 $ 751.41 $ 751.41 90 9% 81% 10% 0 2 0 1 0 0 R

42971 $ 843.76 $ 843.76 90 9% 81% 10% 0 2 0 2 0 0 R

42972 $ 935.47 $ 935.47 90 9% 81% 10% 0 2 0 2 0 0 R


43020 $ 982.27 $ 982.27 90 9% 81% 10% 0 2 0 2 1 0 R

43030 $ 944.96 $ 944.96 90 9% 81% 10% 0 2 0 2 1 0 R

43045 $ 2,332.66 $ 2,332.66 90 9% 81% 10% 0 2 0 2 1 0 R

43100 $ 1,136.60 $ 1,136.60 90 9% 81% 10% 0 2 0 2 1 0 R Y

43101 $ 1,915.84 $ 1,915.84 90 9% 81% 10% 0 2 0 2 1 0 R Y

43107 $ 4,580.57 $ 4,580.57 90 9% 81% 10% 0 2 0 2 1 0 R Y

43108 $ 8,341.41 $ 8,341.41 90 9% 81% 10% 0 2 0 2 1 0 R Y

43112 $ 4,831.67 $ 4,831.67 90 9% 81% 10% 0 2 0 2 2 0 R Y

43113 $ 7,781.02 $ 7,781.02 90 9% 81% 10% 0 2 0 2 2 0 R Y

43116 $ 9,570.99 $ 9,570.99 90 9% 81% 10% 0 2 0 2 1 0 R Y

43117 $ 4,415.48 $ 4,415.48 90 9% 81% 10% 0 2 0 2 2 0 R Y

43118 $ 6,782.30 $ 6,782.30 90 9% 81% 10% 0 2 0 2 2 0 R Y

43121 $ 5,105.54 $ 5,105.54 90 9% 81% 10% 0 2 0 2 2 0 R Y

43122 $ 4,594.48 $ 4,594.48 90 9% 81% 10% 0 2 0 2 1 0 R Y

43123 $ 8,427.43 $ 8,427.43 90 9% 81% 10% 0 2 0 2 1 0 R Y

43124 $ 6,888.56 $ 6,888.56 90 9% 81% 10% 0 2 0 2 1 0 R Y



43180 $ 1,000.62 $ 1,000.62 90 9% 81% 10% 0 2 0 1 0 0 R Y

43191 $ 282.10 $ 282.10 0 0% 0% 0% 0 2 0 1 0 0 R Y

43192 $ 311.19 $ 311.19 0 0% 0% 0% 0 3 0 1 0 0 43191 R

43193 $ 309.93 $ 309.93 0 0% 0% 0% 0 3 0 1 0 0 43191 R Y

43194 $ 350.41 $ 350.41 0 0% 0% 0% 0 3 0 1 0 0 43191 R

43195 $ 338.39 $ 338.39 0 0% 0% 0% 0 3 0 1 0 0 43191 R

43196 $ 360.53 $ 360.53 0 0% 0% 0% 0 3 0 1 0 0 43191 R

43197 $ 347.88 $ 150.54 0 0% 0% 0% 0 2 0 1 0 0 R Y

43198 $ 385.19 $ 180.26 0 0% 0% 0% 0 3 0 1 0 0 43197 R Y

43200 $ 401.01 $ 161.29 0 0% 0% 0% 0 2 0 1 0 0 R Y

43201 $ 407.96 $ 190.38 0 0% 0% 0% 0 3 0 1 0 0 43200 R

43202 $ 570.52 $ 191.02 0 0% 0% 0% 0 3 0 1 0 0 43200 R Y

43204 $ 252.37 $ 252.37 0 0% 0% 0% 0 3 0 1 0 0 43200 R Y

43205 $ 262.49 $ 262.49 0 0% 0% 0% 0 3 0 1 0 0 43200 R Y

43206 $ 490.82 $ 247.94 0 0% 0% 0% 0 3 0 1 0 0 43200 R Y

43210 $ 789.36 $ 789.36 0 0% 0% 0% 0 3 0 1 0 0 43235 R Y

43211 $ 437.06 $ 437.06 0 0% 0% 0% 0 3 0 1 0 0 43200 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


43212 $ 348.51 $ 348.51 0 0% 0% 0% 0 3 0 1 0 0 43200 R

43213 $ 2,149.24 $ 477.54 0 0% 0% 0% 0 3 0 1 0 0 43200 R

43214 $ 356.10 $ 356.10 0 0% 0% 0% 0 3 0 1 0 0 43200 R

43215 $ 666.02 $ 261.22 0 0% 0% 0% 0 3 0 1 0 0 43200 R



43220 $ 2,014.51 $ 218.21 0 0% 0% 0% 0 3 0 1 0 0 43200 R

43226 $ 586.96 $ 240.98 0 0% 0% 0% 0 3 0 1 0 0 43200 R

43227 $ 1,170.76 $ 306.13 0 0% 0% 0% 0 3 0 1 0 0 43200 R


43231 $ 618.59 $ 297.28 0 0% 0% 0% 0 3 0 1 2 0 43200 R

43232 $ 741.92 $ 367.48 0 0% 0% 0% 0 3 0 1 2 0 43200 R

43233 $ 421.25 $ 421.25 0 0% 0% 0% 0 3 0 1 0 0 43235 R

43235 $ 472.48 $ 227.70 0 0% 0% 0% 0 2 0 1 0 0 R Y

43236 $ 608.47 $ 257.43 0 0% 0% 0% 0 3 0 1 0 0 43235 R



43239 $ 634.40 $ 258.06 0 0% 0% 0% 0 3 0 1 0 0 43235 R Y

43240 $ 728.01 $ 728.01 0 0% 0% 0% 0 3 0 1 0 0 43235 R

43241 $ 264.39 $ 264.39 0 0% 0% 0% 0 3 0 1 0 0 43235 R

43242 $ 488.29 $ 488.29 0 0% 0% 0% 0 3 0 1 0 0 43235 R

43243 $ 439.59 $ 439.59 0 0% 0% 0% 0 3 0 1 0 0 43235 R Y

43244 $ 456.03 $ 456.03 0 0% 0% 0% 0 3 0 1 0 0 43235 R Y

43245 $ 1,025.28 $ 324.47 0 0% 0% 0% 0 3 0 1 0 0 43235 R

43246 $ 369.38 $ 369.38 0 0% 0% 0% 0 3 0 0 2 0 43235 R

43247 $ 643.89 $ 327.64 0 0% 0% 0% 0 3 0 1 0 0 43235 R

43248 $ 646.42 $ 308.03 0 0% 0% 0% 0 3 0 1 0 0 43235 R

43249 $ 1,905.09 $ 285.26 0 0% 0% 0% 0 3 0 1 0 0 43235 R

43250 $ 733.07 $ 314.35 0 0% 0% 0% 0 3 0 1 0 0 43235 R

43251 $ 812.76 $ 363.69 0 0% 0% 0% 0 3 0 1 0 0 43235 R

43252 $ 554.07 $ 311.82 0 0% 0% 0% 0 3 0 1 0 0 43235 R Y

43253 $ 488.29 $ 488.29 0 0% 0% 0% 0 3 0 1 0 0 43235 R

43254 $ 502.21 $ 502.21 0 0% 0% 0% 0 3 0 1 0 0 43235 R

43255 $ 1,236.54 $ 373.18 0 0% 0% 0% 0 3 0 1 0 0 43235 R


43259 $ 419.98 $ 419.98 0 0% 0% 0% 0 3 0 1 0 0 43235 R

43260 $ 598.35 $ 598.35 0 0% 0% 0% 0 2 0 1 0 0 R Y

43261 $ 628.71 $ 628.71 0 0% 0% 0% 0 3 0 1 0 0 43260 R Y

43262 $ 662.86 $ 662.86 0 0% 0% 0% 0 3 0 1 0 0 43260 R Y

43263 $ 664.13 $ 664.13 0 0% 0% 0% 0 3 0 1 0 0 43260 R Y

43264 $ 676.14 $ 676.14 0 0% 0% 0% 0 3 0 1 0 0 43260 R Y

43265 $ 804.54 $ 804.54 0 0% 0% 0% 0 3 0 1 0 0 43260 R Y

43266 $ 404.17 $ 404.17 0 0% 0% 0% 0 3 0 1 0 0 43235 R


43273 $ 221.38 $ 221.38 0 0% 0% 0% 0 0 0 0 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


43274 $ 858.94 $ 858.94 0 0% 0% 0% 0 3 0 1 0 0 43260 R

43275 $ 698.91 $ 698.91 0 0% 0% 0% 0 3 0 1 0 0 43260 R

43276 $ 894.36 $ 894.36 0 0% 0% 0% 0 3 0 1 0 0 43260 R

43277 $ 702.71 $ 702.71 0 0% 0% 0% 0 3 0 1 0 0 43260 R


43279 $ 2,314.32 $ 2,314.32 90 9% 81% 10% 0 2 0 2 1 0 R Y

43280 $ 1,939.88 $ 1,939.88 90 9% 81% 10% 0 2 0 2 1 0 R Y

43281 $ 2,767.19 $ 2,767.19 90 9% 81% 10% 0 2 0 2 1 0 R Y

43282 $ 3,111.27 $ 3,111.27 90 9% 81% 10% 0 2 0 2 1 0 R Y

43283 $ 283.36 $ 283.36 0 0% 0% 0% 0 0 0 2 1 0 R Y

43284 $ 1,168.86 $ 1,168.86 090 9% 81% 10% 0 2 0 2 1 0 R Y-UR

43285 $ 1,180.88 $ 1,180.88 090 9% 81% 10% 0 2 0 2 1 0 R Y-UR


43300 $ 1,130.28 $ 1,130.28 90 9% 81% 10% 0 2 0 2 1 0 R Y

43305 $ 1,986.05 $ 1,986.05 90 9% 81% 10% 0 2 0 2 1 0 R Y

43310 $ 2,639.42 $ 2,639.42 90 9% 81% 10% 0 2 0 2 1 0 R Y

43312 $ 2,888.63 $ 2,888.63 90 9% 81% 10% 0 2 0 2 1 0 R Y



43320 $ 2,493.95 $ 2,493.95 90 9% 81% 10% 0 2 0 2 1 0 R Y

43325 $ 2,399.71 $ 2,399.71 90 9% 81% 10% 0 2 0 2 1 0 R Y

43327 $ 1,474.36 $ 1,474.36 90 9% 81% 10% 0 2 0 2 1 0 R

43328 $ 2,018.31 $ 2,018.31 90 9% 81% 10% 0 2 0 2 1 0 R Y

43330 $ 2,394.65 $ 2,394.65 90 9% 81% 10% 0 2 0 2 1 0 R Y

43331 $ 2,402.87 $ 2,402.87 90 9% 81% 10% 0 2 0 2 1 0 R Y

43332 $ 2,082.82 $ 2,082.82 90 9% 81% 10% 0 2 0 2 1 0 R Y

43333 $ 2,271.31 $ 2,271.31 90 9% 81% 10% 0 2 0 2 1 0 R Y

43334 $ 2,239.68 $ 2,239.68 90 9% 81% 10% 0 2 0 2 1 0 R Y

43335 $ 2,400.34 $ 2,400.34 90 9% 81% 10% 0 2 0 2 1 0 R Y

43336 $ 2,706.47 $ 2,706.47 90 9% 81% 10% 0 2 0 2 1 0 R Y

43337 $ 2,915.83 $ 2,915.83 90 9% 81% 10% 0 2 0 2 1 0 R Y

43338 $ 206.83 $ 206.83 0 0% 0% 0% 0 0 0 2 1 0 R Y

43340 $ 2,454.73 $ 2,454.73 90 9% 81% 10% 0 2 0 2 1 0 R Y

43341 $ 2,515.45 $ 2,515.45 90 9% 81% 10% 0 2 0 2 1 0 R Y

43351 $ 2,488.26 $ 2,488.26 90 9% 81% 10% 0 2 0 2 1 0 R Y

43352 $ 1,923.43 $ 1,923.43 90 9% 81% 10% 0 2 0 2 1 0 R Y

43360 $ 4,242.81 $ 4,242.81 90 9% 81% 10% 0 2 0 2 1 0 R Y

43361 $ 4,626.11 $ 4,626.11 90 9% 81% 10% 0 2 0 2 1 0 R Y

43400 $ 2,727.34 $ 2,727.34 90 9% 81% 10% 0 2 0 2 1 0 R Y

43401 $ 2,691.29 $ 2,691.29 90 9% 81% 10% 0 2 0 2 1 0 R Y

43405 $ 2,759.60 $ 2,759.60 90 9% 81% 10% 0 2 0 2 1 0 R Y

43410 $ 1,897.50 $ 1,897.50 90 9% 81% 10% 0 2 0 2 1 0 R

43415 $ 4,609.03 $ 4,609.03 90 9% 81% 10% 0 2 0 2 1 0 R

43420 $ 1,852.59 $ 1,852.59 90 9% 81% 10% 0 2 0 0 1 0 R Y

43425 $ 2,616.02 $ 2,616.02 90 9% 81% 10% 0 2 0 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


43450 $ 289.69 $ 148.01 0 0% 0% 0% 0 2 0 1 0 0 R

43453 $ 1,709.65 $ 160.02 0 0% 0% 0% 0 2 0 1 0 0 R

43460 $ 395.31 $ 395.31 0 0% 0% 0% 0 2 0 1 0 0 R Y



43500 $ 1,414.90 $ 1,414.90 90 9% 81% 10% 0 2 0 2 1 0 R

43501 $ 2,414.25 $ 2,414.25 90 9% 81% 10% 0 2 0 2 1 0 R

43502 $ 2,692.55 $ 2,692.55 90 9% 81% 10% 0 2 0 2 1 0 R

43510 $ 1,660.31 $ 1,660.31 90 9% 81% 10% 0 2 0 2 1 0 R


43605 $ 1,508.51 $ 1,508.51 90 9% 81% 10% 0 2 0 2 1 0 R Y

43610 $ 1,758.35 $ 1,758.35 90 9% 81% 10% 0 2 0 2 1 0 R Y


43620 $ 3,527.45 $ 3,527.45 90 9% 81% 10% 0 2 0 2 1 0 R Y

43621 $ 4,062.55 $ 4,062.55 90 9% 81% 10% 0 2 0 2 1 0 R Y

43622 $ 4,109.99 $ 4,109.99 90 9% 81% 10% 0 2 0 2 1 0 R Y

43631 $ 2,600.84 $ 2,600.84 90 9% 81% 10% 0 2 0 2 1 0 R Y

43632 $ 3,639.41 $ 3,639.41 90 9% 81% 10% 0 2 0 2 1 0 R Y

43633 $ 3,442.07 $ 3,442.07 90 9% 81% 10% 0 2 0 2 1 0 R Y

43634 $ 3,796.27 $ 3,796.27 90 9% 81% 10% 0 2 0 2 1 0 R Y

43635 $ 201.77 $ 201.77 0 0% 0% 0% 0 0 0 2 1 0 R Y

43640 $ 2,115.71 $ 2,115.71 90 9% 81% 10% 0 2 0 2 1 0 R Y

43641 $ 2,147.34 $ 2,147.34 90 9% 81% 10% 0 2 0 2 1 0 R Y





43651 $ 1,174.55 $ 1,174.55 90 11% 76% 13% 0 2 0 2 1 0 R Y

43652 $ 1,375.06 $ 1,375.06 90 11% 76% 13% 0 2 0 2 1 0 R Y

43653 $ 1,034.77 $ 1,034.77 90 9% 81% 10% 0 2 0 2 1 0 R Y


43752 $ 74.64 $ 74.64 0 0% 0% 0% 0 0 0 1 0 0 R

43753 $ 39.22 $ 39.22 0 0% 0% 0% 0 0 0 2 0 0 R

43754 $ 228.97 $ 65.15 0 0% 0% 0% 0 0 0 2 0 0 R

43755 $ 254.90 $ 110.06 0 0% 0% 0% 0 0 0 2 0 0 R

43756 $ 378.24 $ 93.61 0 0% 0% 0% 0 0 0 2 0 0 R

43757 $ 543.32 $ 142.95 0 0% 0% 0% 0 0 0 2 0 0 R

43760 $ 920.92 $ 85.39 0 0% 0% 0% 0 2 0 1 0 0 R

43761 $ 213.15 $ 187.85 0 0% 0% 0% 0 2 0 1 0 0 R









Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


43800 $ 1,669.80 $ 1,669.80 90 9% 81% 10% 0 2 0 2 1 0 R Y

43810 $ 1,821.60 $ 1,821.60 90 9% 81% 10% 0 2 0 2 1 0 R Y

43820 $ 2,406.66 $ 2,406.66 90 9% 81% 10% 0 2 0 2 1 0 R Y

43825 $ 2,321.28 $ 2,321.28 90 9% 81% 10% 0 2 0 2 1 0 R Y

43830 $ 1,259.94 $ 1,259.94 90 9% 81% 10% 0 2 0 2 1 0 R


43832 $ 1,862.08 $ 1,862.08 90 9% 81% 10% 0 2 0 2 1 0 R

43840 $ 2,437.66 $ 2,437.66 90 9% 81% 10% 0 2 0 2 1 0 R







43850 $ 2,896.85 $ 2,896.85 90 9% 81% 10% 0 2 0 2 1 0 R Y

43855 $ 3,027.15 $ 3,027.15 90 9% 81% 10% 0 2 0 2 1 0 R Y

43860 $ 2,932.90 $ 2,932.90 90 9% 81% 10% 0 2 0 2 1 0 R Y

43865 $ 3,040.43 $ 3,040.43 90 9% 81% 10% 0 2 0 2 1 0 R Y

43870 $ 1,279.55 $ 1,279.55 90 9% 81% 10% 0 2 0 2 1 0 R








44005 $ 1,965.18 $ 1,965.18 90 9% 81% 10% 0 2 0 2 1 0 R

44010 $ 1,559.75 $ 1,559.75 90 9% 81% 10% 0 2 0 2 1 0 R

44015 $ 254.27 $ 254.27 0 0% 0% 0% 0 0 0 2 1 0 R

44020 $ 1,746.97 $ 1,746.97 90 9% 81% 10% 0 2 0 2 1 0 R

44021 $ 1,750.13 $ 1,750.13 90 9% 81% 10% 0 2 0 2 1 0 R

44025 $ 1,768.47 $ 1,768.47 90 9% 81% 10% 0 2 0 2 1 0 R

44050 $ 1,678.02 $ 1,678.02 90 9% 81% 10% 0 2 0 2 1 0 R

44055 $ 2,673.58 $ 2,673.58 90 9% 81% 10% 0 2 0 2 1 0 R

44100 $ 199.24 $ 199.24 0 0% 0% 0% 0 2 0 1 0 0 R Y

44110 $ 1,533.18 $ 1,533.18 90 9% 81% 10% 0 2 0 2 1 0 R Y

44111 $ 1,768.47 $ 1,768.47 90 9% 81% 10% 0 2 0 2 1 0 R Y

44120 $ 2,195.41 $ 2,195.41 90 9% 81% 10% 0 2 0 2 1 0 R Y

44121 $ 433.26 $ 433.26 0 0% 0% 0% 0 0 0 2 1 0 R Y

44125 $ 2,122.04 $ 2,122.04 90 9% 81% 10% 0 2 0 2 1 0 R Y




44130 $ 2,359.86 $ 2,359.86 90 9% 81% 10% 0 2 0 2 1 0 R Y




Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY






44139 $ 217.58 $ 217.58 0 0% 0% 0% 0 0 0 2 1 0 R Y

44140 $ 2,410.46 $ 2,410.46 90 9% 81% 10% 0 2 0 2 1 0 R Y

44141 $ 3,289.00 $ 3,289.00 90 9% 81% 10% 0 2 0 2 1 0 R Y

44143 $ 2,994.26 $ 2,994.26 90 9% 81% 10% 0 2 0 2 1 0 R Y

44144 $ 3,180.21 $ 3,180.21 90 9% 81% 10% 0 2 0 2 1 0 R Y

44145 $ 2,984.14 $ 2,984.14 90 9% 81% 10% 0 2 0 2 1 0 R Y

44146 $ 3,829.16 $ 3,829.16 90 9% 81% 10% 0 2 0 2 1 0 R Y

44147 $ 3,489.50 $ 3,489.50 90 9% 81% 10% 0 2 0 2 1 0 R Y

44150 $ 3,375.65 $ 3,375.65 90 9% 81% 10% 0 2 0 2 1 0 R Y

44151 $ 3,846.87 $ 3,846.87 90 9% 81% 10% 0 2 0 2 1 0 R Y

44155 $ 3,771.60 $ 3,771.60 90 9% 81% 10% 0 2 0 2 1 0 R Y

44156 $ 4,075.83 $ 4,075.83 90 9% 81% 10% 0 2 0 2 1 0 R Y

44157 $ 3,897.47 $ 3,897.47 90 9% 81% 10% 0 2 0 2 1 0 R Y

44158 $ 4,014.48 $ 4,014.48 90 9% 81% 10% 0 2 0 2 1 0 R Y

44160 $ 2,232.73 $ 2,232.73 90 9% 81% 10% 0 2 0 2 1 0 R Y

44180 $ 1,652.72 $ 1,652.72 90 9% 81% 10% 0 2 0 2 1 0 R

44186 $ 1,171.39 $ 1,171.39 90 9% 84% 7% 0 2 0 2 1 0 R

44187 $ 2,005.66 $ 2,005.66 90 9% 81% 10% 0 2 0 2 1 0 R

44188 $ 2,216.28 $ 2,216.28 90 9% 81% 10% 0 2 0 2 1 0 R

44202 $ 2,490.15 $ 2,490.15 90 9% 81% 10% 0 2 0 2 1 0 R Y

44203 $ 432.63 $ 432.63 0 0% 0% 0% 0 0 0 2 1 0 R Y

44204 $ 2,770.35 $ 2,770.35 90 9% 81% 10% 0 2 0 2 1 0 R Y

44205 $ 2,411.72 $ 2,411.72 90 9% 81% 10% 0 2 0 2 1 0 R Y

44206 $ 3,154.91 $ 3,154.91 90 9% 81% 10% 0 2 0 2 1 0 R Y

44207 $ 3,282.68 $ 3,282.68 90 9% 81% 10% 0 2 0 2 1 0 R Y

44208 $ 3,590.70 $ 3,590.70 90 9% 81% 10% 0 2 0 2 1 0 R Y

44210 $ 3,226.38 $ 3,226.38 90 9% 81% 10% 0 2 0 2 1 0 R Y

44211 $ 3,965.14 $ 3,965.14 90 9% 81% 10% 0 2 0 2 1 0 R Y

44212 $ 3,718.47 $ 3,718.47 90 9% 81% 10% 0 2 0 2 1 0 R Y

44213 $ 339.02 $ 339.02 0 0% 0% 0% 0 0 0 2 1 0 R

44227 $ 2,998.05 $ 2,998.05 90 9% 81% 10% 0 2 0 2 1 0 R


44300 $ 1,512.31 $ 1,512.31 90 9% 81% 10% 0 2 0 2 1 0 R

44310 $ 1,881.69 $ 1,881.69 90 9% 81% 10% 0 2 0 2 1 0 R Y

44312 $ 1,070.82 $ 1,070.82 90 9% 81% 10% 0 2 0 0 0 0 R Y

44314 $ 1,814.64 $ 1,814.64 90 9% 81% 10% 0 2 0 2 1 0 R Y

44316 $ 2,545.18 $ 2,545.18 90 9% 81% 10% 0 2 0 2 1 0 R Y

44320 $ 2,163.78 $ 2,163.78 90 9% 81% 10% 0 2 0 2 1 0 R Y

44322 $ 1,811.48 $ 1,811.48 90 9% 81% 10% 0 2 0 2 1 0 R Y

44340 $ 1,129.65 $ 1,129.65 90 9% 81% 10% 0 2 0 1 1 0 R Y

44345 $ 1,898.13 $ 1,898.13 90 9% 81% 10% 0 2 0 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


44346 $ 2,134.06 $ 2,134.06 90 9% 81% 10% 0 2 0 2 1 0 R Y

44360 $ 267.55 $ 267.55 0 0% 0% 0% 0 2 0 1 0 0 R Y

44361 $ 295.38 $ 295.38 0 0% 0% 0% 0 3 0 1 0 0 44360 R

44363 $ 355.47 $ 355.47 0 0% 0% 0% 0 3 0 0 0 0 44360 R



44366 $ 445.91 $ 445.91 0 0% 0% 0% 0 3 0 1 0 0 44360 R


44370 $ 494.62 $ 494.62 0 0% 0% 0% 0 3 0 0 0 0 44360 R Y

44372 $ 445.28 $ 445.28 0 0% 0% 0% 0 3 0 1 0 0 44360 R Y

44373 $ 355.47 $ 355.47 0 0% 0% 0% 0 3 0 1 0 0 44360 R Y

44376 $ 526.87 $ 526.87 0 0% 0% 0% 0 2 0 0 0 0 R Y

44377 $ 555.34 $ 555.34 0 0% 0% 0% 0 3 0 0 0 0 44376 R Y

44378 $ 714.09 $ 714.09 0 0% 0% 0% 0 3 0 0 0 0 44376 R Y

44379 $ 760.90 $ 760.90 0 0% 0% 0% 0 3 0 0 0 0 44376 R Y

44380 $ 313.09 $ 105.00 0 0% 0% 0% 0 2 0 1 0 0 R Y


44382 $ 488.29 $ 136.62 0 0% 0% 0% 0 3 0 1 0 0 44380 R Y


44385 $ 354.20 $ 133.46 0 0% 0% 0% 0 2 0 1 0 0 R Y

44386 $ 530.67 $ 165.08 0 0% 0% 0% 0 2 0 1 0 0 R

44388 $ 529.40 $ 288.42 0 0% 0% 0% 0 2 0 1 0 0 R Y

44389 $ 698.28 $ 318.15 0 0% 0% 0% 0 3 0 1 0 0 44388 R Y

44390 $ 688.16 $ 391.52 0 0% 0% 0% 0 3 0 1 0 0 44388 R Y

44391 $ 1,286.51 $ 426.94 0 0% 0% 0% 0 3 0 1 0 0 44388 R Y

44392 $ 641.99 $ 365.59 0 0% 0% 0% 0 3 0 1 0 0 44388 R Y

44394 $ 741.29 $ 417.45 0 0% 0% 0% 0 3 0 1 0 0 44388 R Y









44500 $ 35.42 $ 35.42 0 0% 0% 0% 0 0 0 0 0 0 R Y

44602 $ 2,529.37 $ 2,529.37 90 9% 81% 10% 0 2 0 2 1 0 R

44603 $ 2,908.87 $ 2,908.87 90 9% 81% 10% 0 2 0 2 1 0 R

44604 $ 1,899.40 $ 1,899.40 90 9% 81% 10% 0 2 0 2 1 0 R

44605 $ 2,344.05 $ 2,344.05 90 9% 81% 10% 0 2 0 2 1 0 R

44615 $ 1,931.02 $ 1,931.02 90 9% 81% 10% 0 2 0 2 1 0 R Y

44620 $ 1,566.07 $ 1,566.07 90 9% 81% 10% 0 2 0 2 1 0 R Y

44625 $ 1,836.15 $ 1,836.15 90 9% 81% 10% 0 2 0 2 1 0 R Y

44626 $ 2,879.77 $ 2,879.77 90 9% 81% 10% 0 2 0 2 1 0 R Y

44640 $ 2,521.15 $ 2,521.15 90 9% 81% 10% 0 2 0 2 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


44650 $ 2,600.84 $ 2,600.84 90 9% 81% 10% 0 2 0 2 1 0 R

44660 $ 2,420.58 $ 2,420.58 90 9% 81% 10% 0 2 0 2 1 0 R

44661 $ 2,793.75 $ 2,793.75 90 9% 81% 10% 0 2 0 2 1 0 R

44680 $ 1,916.48 $ 1,916.48 90 9% 81% 10% 0 2 0 2 1 0 R Y


44701 $ 301.70 $ 301.70 0 0% 0% 0% 0 0 0 2 1 0 R



44720 $ 554.70 $ 554.70 0 0% 0% 0% 0 2 0 2 1 0 R

44721 $ 686.90 $ 686.90 0 0% 0% 0% 0 2 0 2 1 0 R




44850 $ 1,349.76 $ 1,349.76 90 9% 81% 10% 0 2 0 2 1 0 R


44900 $ 1,382.01 $ 1,382.01 90 9% 81% 10% 0 2 0 2 1 0 R Y

44950 $ 1,152.42 $ 1,152.42 90 9% 81% 10% 0 2 0 2 1 0 R Y


44960 $ 1,568.60 $ 1,568.60 90 9% 81% 10% 0 2 0 2 1 0 R Y



45000 $ 771.02 $ 771.02 90 9% 81% 10% 0 2 0 1 0 0 R

45005 $ 507.90 $ 294.75 10 10% 80% 10% 0 2 0 1 0 0 R

45020 $ 1,037.30 $ 1,037.30 90 9% 81% 10% 0 2 0 1 0 0 R

45100 $ 547.11 $ 547.11 90 9% 81% 10% 0 2 0 1 0 0 R Y

45108 $ 660.33 $ 660.33 90 9% 81% 10% 0 2 0 1 1 0 R Y

45110 $ 3,342.76 $ 3,342.76 90 9% 81% 10% 0 2 0 2 1 0 R Y

45111 $ 1,962.02 $ 1,962.02 90 9% 81% 10% 0 2 0 2 1 0 R Y

45112 $ 3,395.26 $ 3,395.26 90 9% 81% 10% 0 2 0 2 1 0 R Y

45113 $ 3,504.05 $ 3,504.05 90 9% 81% 10% 0 2 0 2 1 0 R Y

45114 $ 3,240.93 $ 3,240.93 90 9% 81% 10% 0 2 0 2 1 0 R Y

45116 $ 2,910.13 $ 2,910.13 90 9% 81% 10% 0 2 0 2 1 0 R Y

45119 $ 3,529.98 $ 3,529.98 90 9% 81% 10% 0 2 0 2 1 0 R Y

45120 $ 2,848.78 $ 2,848.78 90 9% 81% 10% 0 2 0 2 1 0 R Y

45121 $ 3,018.92 $ 3,018.92 90 9% 81% 10% 0 2 0 2 1 0 R Y

45123 $ 2,032.22 $ 2,032.22 90 9% 81% 10% 0 2 0 2 1 0 R Y

45126 $ 5,056.84 $ 5,056.84 90 12% 74% 14% 0 2 0 2 1 0 R Y

45130 $ 1,977.20 $ 1,977.20 90 9% 81% 10% 0 2 0 2 1 0 R Y

45135 $ 2,457.90 $ 2,457.90 90 9% 81% 10% 0 2 0 2 1 0 R Y

45136 $ 3,434.48 $ 3,434.48 90 9% 81% 10% 0 2 0 2 1 0 R Y

45150 $ 662.86 $ 662.86 90 9% 81% 10% 0 2 0 0 0 0 R Y







Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


45300 $ 228.97 $ 99.30 0 0% 0% 0% 0 2 0 1 0 0 R Y

45303 $ 1,697.63 $ 158.13 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y

45305 $ 262.49 $ 134.09 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y

45307 $ 304.87 $ 177.73 0 0% 0% 0% 0 3 0 0 0 0 45300 R Y

45308 $ 292.22 $ 151.80 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y

45309 $ 304.23 $ 161.29 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y

45315 $ 329.53 $ 190.38 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y

45317 $ 333.96 $ 204.93 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y

45320 $ 323.21 $ 188.49 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y

45321 $ 184.69 $ 184.69 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y

45327 $ 208.73 $ 208.73 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y

45330 $ 310.56 $ 104.36 0 0% 0% 0% 0 2 0 1 0 0 R Y

45331 $ 478.17 $ 134.09 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y

45332 $ 464.26 $ 194.81 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y

45333 $ 545.22 $ 173.94 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y

45334 $ 1,029.71 $ 218.85 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y

45335 $ 435.79 $ 123.34 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y

45337 $ 213.15 $ 213.15 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y

45338 $ 495.88 $ 223.27 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y

45340 $ 807.70 $ 144.21 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y

45341 $ 230.23 $ 230.23 0 0% 0% 0% 0 2 0 1 0 0 45330 R Y

45342 $ 315.62 $ 315.62 0 0% 0% 0% 0 2 0 1 0 0 45330 R Y





45378 $ 579.37 $ 342.82 0 0% 0% 0% 0 2 0 1 0 0 R Y

45378-53 $ 290.32 $ 172.04 0 0% 0% 0% 0 2 0 1 0 0 R Y

45379 $ 746.98 $ 442.75 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y

45380 $ 745.72 $ 371.91 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y


45382 $ 1,336.47 $ 480.70 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y

45384 $ 824.78 $ 421.25 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y

45385 $ 778.61 $ 471.85 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y

45386 $ 1,083.47 $ 392.15 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y




45391 $ 478.17 $ 478.17 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y

45392 $ 564.19 $ 564.19 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y


45395 $ 3,588.81 $ 3,588.81 90 9% 81% 10% 0 2 0 2 1 0 R Y

45397 $ 3,913.91 $ 3,913.91 90 9% 81% 10% 0 2 0 2 1 0 R Y





Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


45400 $ 2,070.17 $ 2,070.17 90 9% 81% 10% 0 2 0 2 1 0 R Y

45402 $ 2,753.27 $ 2,753.27 90 9% 81% 10% 0 2 0 2 1 0 R Y


45500 $ 957.61 $ 957.61 90 9% 81% 10% 0 2 0 0 0 0 R Y

45505 $ 1,079.68 $ 1,079.68 90 9% 81% 10% 0 2 0 1 0 0 R Y

45520 $ 291.58 $ 74.64 0 0% 0% 0% 0 2 0 1 0 0 R Y

45540 $ 1,916.48 $ 1,916.48 90 9% 81% 10% 0 2 0 2 1 0 R Y

45541 $ 1,709.02 $ 1,709.02 90 9% 81% 10% 0 2 0 2 1 0 R Y

45550 $ 2,650.18 $ 2,650.18 90 9% 81% 10% 0 2 0 2 1 0 R Y

45560 $ 1,256.78 $ 1,256.78 90 9% 81% 10% 0 2 0 2 1 0 R Y

45562 $ 2,030.96 $ 2,030.96 90 9% 81% 10% 0 2 0 2 1 0 R Y

45563 $ 2,953.14 $ 2,953.14 90 9% 81% 10% 0 2 0 2 1 0 R Y

45800 $ 2,180.86 $ 2,180.86 90 9% 81% 10% 0 2 0 2 1 0 R Y

45805 $ 2,591.35 $ 2,591.35 90 9% 81% 10% 0 2 0 2 1 0 R Y

45820 $ 2,066.38 $ 2,066.38 90 9% 81% 10% 0 2 0 2 1 0 R Y

45825 $ 2,617.92 $ 2,617.92 90 9% 81% 10% 0 2 0 2 1 0 R Y

45900 $ 368.12 $ 368.12 10 10% 80% 10% 0 2 0 0 0 0 R Y

45905 $ 308.03 $ 308.03 10 10% 80% 10% 0 2 0 1 0 0 R Y

45910 $ 353.57 $ 353.57 10 10% 80% 10% 0 2 0 1 0 0 R Y

45915 $ 611.63 $ 415.55 10 10% 80% 10% 0 2 0 1 0 0 R Y

45990 $ 194.81 $ 194.81 0 0% 0% 0% 0 2 0 0 1 1 R


46020 $ 506.63 $ 428.20 10 10% 80% 10% 0 2 0 1 0 0 R

46030 $ 256.16 $ 165.08 10 10% 80% 10% 0 2 0 0 0 0 R

46040 $ 981.01 $ 755.21 90 9% 81% 10% 0 2 0 1 0 0 R

46045 $ 791.26 $ 791.26 90 9% 81% 10% 0 2 0 1 0 0 R

46050 $ 374.44 $ 178.37 10 10% 80% 10% 0 2 0 1 0 0 R

46060 $ 869.06 $ 869.06 90 9% 81% 10% 0 2 0 1 0 0 R


46080 $ 454.14 $ 288.42 10 10% 80% 10% 0 2 0 1 0 0 R

46083 $ 326.37 $ 194.81 10 10% 80% 10% 0 2 0 1 0 0 R

46200 $ 824.78 $ 599.61 90 9% 81% 10% 0 2 0 1 0 0 R

46220 $ 380.77 $ 216.32 10 10% 80% 10% 0 2 0 1 0 0 R

46221 $ 495.25 $ 349.77 10 10% 80% 10% 0 2 0 1 0 0 R

46230 $ 502.21 $ 313.72 10 10% 80% 10% 0 2 0 1 0 0 R

46250 $ 851.35 $ 573.68 90 9% 81% 10% 0 2 0 1 0 0 R

46255 $ 929.14 $ 643.25 90 9% 81% 10% 0 2 0 1 0 0 R

46257 $ 765.96 $ 765.96 90 9% 81% 10% 0 2 0 1 0 0 R

46258 $ 838.06 $ 838.06 90 9% 81% 10% 0 2 0 0 0 0 R

46260 $ 864.00 $ 864.00 90 9% 81% 10% 0 2 0 1 0 0 R

46261 $ 949.38 $ 949.38 90 9% 81% 10% 0 2 0 1 0 0 R

46262 $ 1,008.21 $ 1,008.21 90 9% 81% 10% 0 2 0 1 0 0 R

46270 $ 932.31 $ 714.73 90 9% 81% 10% 0 2 0 1 0 0 R

46275 $ 989.23 $ 756.47 90 9% 81% 10% 0 2 0 1 0 0 R

46280 $ 857.04 $ 857.04 90 9% 81% 10% 0 2 0 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


46285 $ 983.54 $ 756.47 90 9% 81% 10% 0 2 0 1 0 0 R

46288 $ 1,003.15 $ 1,003.15 90 9% 81% 10% 0 2 0 1 0 0 R

46320 $ 338.39 $ 201.77 10 10% 80% 10% 0 2 0 1 0 0 R

46500 $ 347.88 $ 227.07 10 10% 80% 10% 0 2 0 1 0 0 R

46505 $ 521.81 $ 435.79 10 10% 80% 10% 0 2 1 1 0 0 R

46600 $ 164.45 $ 75.27 0 0% 0% 0% 0 2 0 1 0 0 R


46604 $ 1,170.76 $ 122.07 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y

46606 $ 421.25 $ 138.52 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y


46608 $ 434.53 $ 150.54 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y

46610 $ 423.14 $ 148.01 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y

46611 $ 326.37 $ 148.64 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y

46612 $ 462.36 $ 166.35 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y

46614 $ 237.19 $ 118.28 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y

46615 $ 261.86 $ 168.25 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y

46700 $ 1,191.63 $ 1,191.63 90 9% 81% 10% 0 2 0 1 0 0 R Y


46706 $ 315.62 $ 315.62 10 10% 80% 10% 0 2 0 1 0 0 R

46707 $ 858.94 $ 858.94 90 9% 81% 10% 0 2 0 0 0 0 R












46750 $ 1,375.69 $ 1,375.69 90 9% 81% 10% 0 2 0 2 1 0 R Y


46753 $ 1,056.91 $ 1,056.91 90 9% 81% 10% 0 2 0 1 0 0 R Y

46754 $ 548.38 $ 422.51 10 10% 80% 10% 0 2 0 0 0 0 R

46760 $ 2,022.10 $ 2,022.10 90 9% 81% 10% 0 2 0 2 1 0 R Y

46761 $ 1,681.19 $ 1,681.19 90 9% 81% 10% 0 2 0 2 1 0 R Y

46762 $ 1,670.43 $ 1,670.43 90 9% 81% 10% 0 2 0 2 1 0 R Y







46930 $ 381.40 $ 271.98 90 9% 81% 10% 0 2 0 0 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


46940 $ 419.98 $ 266.28 10 10% 80% 10% 0 2 0 1 0 0 R

46942 $ 397.84 $ 239.09 10 10% 80% 10% 0 2 0 0 0 0 R

46945 $ 573.05 $ 417.45 90 9% 81% 10% 0 2 0 1 0 0 R

46946 $ 578.74 $ 413.66 90 9% 81% 10% 0 2 0 1 0 0 R

46947 $ 691.96 $ 691.96 90 9% 81% 10% 0 2 0 1 0 0 R


47000 $ 571.78 $ 165.72 0 0% 0% 0% 0 2 0 1 0 0 R

47001 $ 186.59 $ 186.59 0 0% 0% 0% 0 0 0 1 1 0 R

47010 $ 2,170.11 $ 2,170.11 90 9% 81% 10% 0 2 0 2 1 0 R

47015 $ 2,091.05 $ 2,091.05 90 9% 81% 10% 0 2 0 2 1 0 R Y

47100 $ 1,522.43 $ 1,522.43 90 9% 81% 10% 0 2 0 2 1 0 R Y

47120 $ 4,179.56 $ 4,179.56 90 9% 81% 10% 0 2 0 2 1 0 R Y

47122 $ 6,137.78 $ 6,137.78 90 9% 81% 10% 0 2 0 2 1 0 R Y

47125 $ 5,504.02 $ 5,504.02 90 9% 81% 10% 0 2 0 2 1 0 R Y

47130 $ 5,911.35 $ 5,911.35 90 9% 81% 10% 0 2 0 2 1 0 R Y

47133 $ 4,747.05 $ 4,747.05 0 0% 0% 0% 9 9 9 9 9 9 F Y

47135 $ 9,627.92 $ 9,627.92 90 9% 81% 10% 0 2 0 2 1 2 R Y

47140 $ 6,102.99 $ 6,102.99 90 9% 81% 10% 0 2 0 2 1 2 R Y

47141 $ 7,648.82 $ 7,648.82 90 9% 81% 10% 0 2 0 2 1 2 R Y

47142 $ 8,399.60 $ 8,399.60 90 9% 81% 10% 0 2 0 2 1 0 R Y




47146 $ 588.86 $ 588.86 0 0% 0% 0% 0 2 0 2 1 0 R Y

47147 $ 684.37 $ 684.37 0 0% 0% 0% 0 2 0 2 1 0 R Y

47300 $ 2,038.55 $ 2,038.55 90 9% 81% 10% 0 2 0 2 1 0 R Y

47350 $ 2,460.43 $ 2,460.43 90 9% 81% 10% 0 2 0 2 1 0 R

47360 $ 3,328.22 $ 3,328.22 90 9% 81% 10% 0 2 0 2 1 0 R

47361 $ 5,436.97 $ 5,436.97 90 9% 81% 10% 0 2 0 2 1 0 R

47362 $ 2,605.90 $ 2,605.90 90 9% 81% 10% 0 2 0 2 1 0 R

47370 $ 2,238.42 $ 2,238.42 90 9% 81% 10% 0 2 0 2 1 0 R Y

47371 $ 2,238.42 $ 2,238.42 90 9% 81% 10% 0 2 0 2 1 0 R Y







47400 $ 3,828.52 $ 3,828.52 90 9% 81% 10% 0 2 0 2 1 0 R Y

47420 $ 2,406.66 $ 2,406.66 90 9% 81% 10% 0 2 0 2 1 0 R Y

47425 $ 2,346.58 $ 2,346.58 90 9% 81% 10% 0 2 0 2 1 0 R Y

47460 $ 2,259.29 $ 2,259.29 90 9% 81% 10% 0 2 0 2 1 0 R Y

47480 $ 1,582.52 $ 1,582.52 90 9% 81% 10% 0 2 0 2 1 0 R Y

47490 $ 614.79 $ 614.79 10 10% 80% 10% 0 2 0 1 0 0 R Y

47531 $ 585.70 $ 130.93 0 0% 0% 0% 0 2 0 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


47532 $ 1,495.86 $ 393.42 0 0% 0% 0% 0 2 0 1 0 0 R

47533 $ 2,314.32 $ 493.98 0 0% 0% 0% 0 2 0 1 0 0 R

47534 $ 2,750.74 $ 688.79 0 0% 0% 0% 0 2 0 1 0 0 R

47535 $ 1,903.83 $ 367.48 0 0% 0% 0% 0 2 0 1 0 0 R

47536 $ 1,292.20 $ 246.04 0 0% 0% 0% 0 2 0 1 0 0 R

47537 $ 684.37 $ 179.00 0 0% 0% 0% 0 2 0 1 0 0 R

47538 $ 8,134.58 $ 436.43 0 0% 0% 0% 0 2 0 1 0 0 R

47539 $ 8,985.93 $ 791.26 0 0% 0% 0% 0 2 0 1 0 0 R

47540 $ 9,209.20 $ 819.09 0 0% 0% 0% 0 2 0 1 0 0 R

47541 $ 2,185.92 $ 616.06 0 0% 0% 0% 0 2 0 1 0 0 R

47542 $ 859.57 $ 250.47 0 0% 0% 0% 0 0 0 1 0 0 R

47543 $ 1,069.56 $ 288.42 0 0% 0% 0% 0 0 0 1 0 0 R

47544 $ 2,039.18 $ 296.01 0 0% 0% 0% 0 0 0 1 0 0 R Y

47550 $ 296.01 $ 296.01 0 0% 0% 0% 0 0 0 2 1 0 R

47552 $ 569.25 $ 569.25 0 0% 0% 0% 0 2 0 1 1 0 R

47553 $ 564.19 $ 564.19 0 0% 0% 0% 0 3 0 1 0 0 47552 R

47554 $ 864.00 $ 864.00 0 0% 0% 0% 0 3 0 1 1 0 47552 R

47555 $ 669.82 $ 669.82 0 0% 0% 0% 0 3 0 1 0 0 47552 R

47556 $ 764.06 $ 764.06 0 0% 0% 0% 0 3 0 1 0 0 47552 R

47562 $ 1,182.78 $ 1,182.78 90 9% 81% 10% 0 2 0 2 1 0 R

47563 $ 1,283.34 $ 1,283.34 90 9% 81% 10% 0 2 0 2 1 0 R

47564 $ 1,999.33 $ 1,999.33 90 9% 81% 10% 0 2 0 2 1 0 R

47570 $ 1,393.40 $ 1,393.40 90 9% 81% 10% 0 2 0 2 1 0 R


47600 $ 1,916.48 $ 1,916.48 90 9% 81% 10% 0 2 0 2 1 0 R

47605 $ 2,016.41 $ 2,016.41 90 9% 81% 10% 0 2 0 2 1 0 R

47610 $ 2,250.44 $ 2,250.44 90 9% 81% 10% 0 2 0 2 1 0 R

47612 $ 2,274.47 $ 2,274.47 90 9% 81% 10% 0 2 0 2 1 0 R

47620 $ 2,457.90 $ 2,457.90 90 9% 81% 10% 0 2 0 2 1 0 R


47701 $ 3,076.48 $ 3,076.48 90 9% 81% 10% 0 2 0 0 0 0 R Y



47715 $ 2,381.36 $ 2,381.36 90 9% 81% 10% 0 2 0 2 1 0 R Y

47720 $ 2,057.52 $ 2,057.52 90 9% 81% 10% 0 2 0 2 1 0 R Y

47721 $ 2,423.74 $ 2,423.74 90 9% 81% 10% 0 2 0 2 1 0 R Y

47740 $ 2,350.37 $ 2,350.37 90 9% 81% 10% 0 2 0 2 1 0 R Y

47741 $ 2,606.53 $ 2,606.53 90 9% 81% 10% 0 2 0 2 1 0 R Y

47760 $ 4,038.51 $ 4,038.51 90 9% 81% 10% 0 2 0 2 1 0 R Y

47765 $ 5,440.13 $ 5,440.13 90 9% 81% 10% 0 2 0 2 1 0 R Y

47780 $ 4,430.03 $ 4,430.03 90 9% 81% 10% 0 2 0 2 1 0 R Y

47785 $ 5,805.72 $ 5,805.72 90 9% 81% 10% 0 2 0 2 1 0 R Y

47800 $ 2,832.34 $ 2,832.34 90 9% 81% 10% 0 2 0 2 1 0 R Y

47801 $ 1,827.29 $ 1,827.29 90 9% 81% 10% 0 2 0 2 1 0 R Y

47802 $ 2,733.67 $ 2,733.67 90 9% 81% 10% 0 2 0 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


47900 $ 2,464.22 $ 2,464.22 90 9% 81% 10% 0 2 0 2 1 0 R Y


48000 $ 3,347.82 $ 3,347.82 90 9% 81% 10% 0 2 0 2 1 0 R Y

48001 $ 4,137.18 $ 4,137.18 90 9% 81% 10% 0 2 0 2 1 0 R Y

48020 $ 2,087.25 $ 2,087.25 90 9% 81% 10% 0 2 0 2 1 0 R Y

48100 $ 1,598.96 $ 1,598.96 90 9% 81% 10% 0 2 0 2 1 0 R Y

48102 $ 987.97 $ 444.02 10 10% 80% 10% 0 2 0 1 0 0 R Y

48105 $ 5,104.28 $ 5,104.28 90 9% 81% 10% 0 2 0 2 1 0 R Y

48120 $ 1,986.68 $ 1,986.68 90 9% 81% 10% 0 2 0 2 1 0 R Y

48140 $ 2,803.87 $ 2,803.87 90 9% 81% 10% 0 2 0 2 1 0 R Y

48145 $ 2,910.77 $ 2,910.77 90 9% 81% 10% 0 2 0 2 1 0 R Y

48146 $ 3,364.90 $ 3,364.90 90 9% 81% 10% 0 2 0 2 1 0 R Y

48148 $ 2,230.20 $ 2,230.20 90 9% 81% 10% 0 2 0 2 1 0 R Y

48150 $ 5,579.28 $ 5,579.28 90 9% 81% 10% 0 2 0 2 1 0 R Y

48152 $ 5,171.32 $ 5,171.32 90 9% 81% 10% 0 2 0 2 1 0 R Y

48153 $ 5,548.29 $ 5,548.29 90 9% 81% 10% 0 2 0 2 1 0 R Y

48154 $ 5,169.42 $ 5,169.42 90 9% 81% 10% 0 2 0 2 1 0 R Y

48155 $ 3,264.97 $ 3,264.97 90 9% 81% 10% 0 2 0 2 1 0 R Y


48400 $ 192.28 $ 192.28 0 0% 0% 0% 0 0 0 0 0 0 R Y

48500 $ 2,047.40 $ 2,047.40 90 9% 81% 10% 0 2 0 2 1 0 R Y

48510 $ 1,963.91 $ 1,963.91 90 9% 81% 10% 0 2 0 2 1 0 R Y

48520 $ 1,962.02 $ 1,962.02 90 9% 81% 10% 0 2 0 2 1 0 R Y

48540 $ 2,349.74 $ 2,349.74 90 9% 81% 10% 0 2 0 2 1 0 R Y

48545 $ 2,410.46 $ 2,410.46 90 9% 81% 10% 0 2 0 2 1 0 R

48547 $ 3,202.35 $ 3,202.35 90 9% 81% 10% 0 2 0 2 1 0 R

48548 $ 2,972.75 $ 2,972.75 90 9% 81% 10% 0 2 0 2 1 0 R Y



48552 $ 419.35 $ 419.35 0 0% 0% 0% 0 2 0 2 1 0 R Y

48554 $ 4,615.99 $ 4,615.99 90 9% 81% 10% 0 2 0 2 2 2 R Y

48556 $ 2,285.22 $ 2,285.22 90 9% 81% 10% 0 2 0 2 2 2 R Y


49000 $ 1,385.81 $ 1,385.81 90 9% 81% 10% 0 2 0 2 1 0 R

49002 $ 1,877.26 $ 1,877.26 90 9% 81% 10% 0 2 0 2 1 0 R

49010 $ 1,678.66 $ 1,678.66 90 9% 81% 10% 0 2 0 2 1 0 R

49020 $ 2,858.90 $ 2,858.90 90 9% 81% 10% 0 2 0 2 0 0 R

49040 $ 1,795.67 $ 1,795.67 90 9% 81% 10% 0 2 0 2 1 0 R

49060 $ 1,974.67 $ 1,974.67 90 9% 81% 10% 0 2 0 1 1 0 R

49062 $ 1,330.78 $ 1,330.78 90 9% 81% 10% 0 2 0 2 1 0 R

49082 $ 358.00 $ 135.99 0 0% 0% 0% 0 2 0 1 0 0 R

49083 $ 547.75 $ 199.87 0 0% 0% 0% 0 2 0 1 0 0 R

49084 $ 194.18 $ 194.18 0 0% 0% 0% 0 2 0 1 0 0 R

49180 $ 301.07 $ 156.86 0 0% 0% 0% 0 2 0 1 0 0 R Y

49185 $ 1,839.94 $ 223.91 0 0% 0% 0% 0 0 0 1 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


49203 $ 2,156.19 $ 2,156.19 90 9% 81% 10% 0 2 0 2 1 0 R Y

49204 $ 2,757.07 $ 2,757.07 90 9% 81% 10% 0 2 0 2 1 0 R Y

49205 $ 3,161.87 $ 3,161.87 90 9% 81% 10% 0 2 0 2 1 0 R Y

49215 $ 4,001.83 $ 4,001.83 90 9% 81% 10% 0 2 0 2 1 0 R Y


49250 $ 1,061.97 $ 1,061.97 90 9% 81% 10% 0 2 0 1 1 0 R

49255 $ 1,427.55 $ 1,427.55 90 9% 81% 10% 0 2 0 2 1 0 R

49320 $ 588.86 $ 588.86 10 10% 80% 10% 0 2 0 2 0 0 R

49321 $ 623.01 $ 623.01 10 10% 80% 10% 0 3 0 2 2 0 49320 R Y

49322 $ 667.29 $ 667.29 10 10% 80% 10% 0 3 0 2 2 0 49320 R Y

49323 $ 1,151.78 $ 1,151.78 90 10% 80% 10% 0 3 0 2 2 0 49320 R Y

49324 $ 700.18 $ 700.18 10 10% 80% 10% 0 3 0 2 2 0 49320 R

49325 $ 745.72 $ 745.72 10 10% 80% 10% 0 3 0 2 2 0 49320 R

49326 $ 337.12 $ 337.12 0 0% 0% 0% 0 0 0 2 1 0 R



49400 $ 246.04 $ 169.51 0 0% 0% 0% 0 2 0 1 0 0 R

49402 $ 1,537.61 $ 1,537.61 90 9% 81% 10% 0 2 0 1 1 0 R

49405 $ 1,507.88 $ 364.95 0 0% 0% 0% 0 2 0 1 0 0 R

49406 $ 1,508.51 $ 364.95 0 0% 0% 0% 0 2 0 1 0 0 R

49407 $ 1,219.46 $ 387.72 0 0% 0% 0% 0 2 0 1 0 0 R





49421 $ 411.13 $ 411.13 0 0% 0% 0% 0 2 0 1 0 0 R

49422 $ 683.10 $ 683.10 10 10% 80% 10% 0 2 0 1 0 0 R

49423 $ 1,026.55 $ 131.56 0 0% 0% 0% 0 2 0 0 0 0 R

49424 $ 271.98 $ 70.21 0 0% 0% 0% 0 2 0 0 0 0 R

49425 $ 1,302.95 $ 1,302.95 90 9% 81% 10% 0 2 0 2 1 0 R Y

49426 $ 1,097.39 $ 1,097.39 90 9% 81% 10% 0 2 0 1 0 0 R Y

49427 $ 83.49 $ 83.49 0 0% 0% 0% 0 2 0 0 0 0 R Y

49428 $ 819.09 $ 819.09 10 10% 80% 10% 0 2 0 1 0 0 R Y

49429 $ 824.78 $ 824.78 10 10% 80% 10% 0 2 0 1 0 0 R Y

49435 $ 212.52 $ 212.52 0 0% 0% 0% 0 0 0 2 1 0 R

49436 $ 336.49 $ 336.49 10 10% 80% 10% 0 2 0 2 1 0 R

49440 $ 1,814.64 $ 382.03 10 10% 80% 10% 0 2 0 0 0 0 R

49441 $ 2,044.87 $ 444.02 10 10% 80% 10% 0 2 0 0 0 0 R

49442 $ 1,703.96 $ 386.46 10 10% 80% 10% 0 2 0 0 0 0 R

49446 $ 1,747.60 $ 274.51 0 0% 0% 0% 0 2 0 0 0 0 R

49450 $ 1,252.35 $ 122.71 0 0% 0% 0% 0 2 0 0 0 0 R

49451 $ 1,366.83 $ 165.72 0 0% 0% 0% 0 2 0 0 0 0 R

49452 $ 1,687.51 $ 256.16 0 0% 0% 0% 0 2 0 0 0 0 R

49460 $ 1,387.71 $ 87.92 0 0% 0% 0% 0 2 0 0 0 0 R

49465 $ 308.03 $ 56.93 0 0% 0% 0% 0 2 0 0 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY








49505 $ 937.37 $ 937.37 90 9% 81% 10% 0 2 1 2 1 0 R

49507 $ 1,052.48 $ 1,052.48 90 9% 81% 10% 0 2 1 2 1 0 R

49520 $ 1,135.97 $ 1,135.97 90 9% 81% 10% 0 2 1 2 1 0 R

49521 $ 1,286.51 $ 1,286.51 90 9% 81% 10% 0 2 1 2 1 0 R

49525 $ 1,030.98 $ 1,030.98 90 9% 81% 10% 0 2 1 2 1 0 R

49540 $ 1,209.97 $ 1,209.97 90 9% 81% 10% 0 2 1 2 1 0 R

49550 $ 1,034.77 $ 1,034.77 90 9% 81% 10% 0 2 1 2 1 0 R

49553 $ 1,133.44 $ 1,133.44 90 9% 81% 10% 0 2 1 2 1 0 R

49555 $ 1,074.62 $ 1,074.62 90 9% 81% 10% 0 2 1 2 1 0 R

49557 $ 1,301.05 $ 1,301.05 90 9% 81% 10% 0 2 1 2 1 0 R

49560 $ 1,325.72 $ 1,325.72 90 9% 81% 10% 0 2 1 2 1 0 R

49561 $ 1,667.90 $ 1,667.90 90 9% 81% 10% 0 2 1 2 1 0 R

49565 $ 1,380.75 $ 1,380.75 90 9% 81% 10% 0 2 1 2 1 0 R

49566 $ 1,683.08 $ 1,683.08 90 9% 81% 10% 0 2 1 2 1 0 R

49568 $ 477.54 $ 477.54 0 0% 0% 0% 0 0 0 2 1 0 R

49570 $ 752.68 $ 752.68 90 9% 81% 10% 0 2 1 2 1 0 R

49572 $ 929.14 $ 929.14 90 9% 81% 10% 0 2 1 2 1 0 R



49585 $ 802.64 $ 802.64 90 9% 81% 10% 0 2 0 2 1 0 R

49587 $ 856.41 $ 856.41 90 9% 81% 10% 0 2 0 2 1 0 R

49590 $ 1,030.34 $ 1,030.34 90 9% 81% 10% 0 2 1 2 1 0 R

49600 $ 1,206.81 $ 1,206.81 90 9% 81% 10% 0 2 0 2 1 0 R Y

49605 $ 8,829.70 $ 8,829.70 90 9% 81% 10% 0 2 0 2 1 0 R Y

49606 $ 2,029.69 $ 2,029.69 90 9% 81% 10% 0 2 0 2 1 0 R Y

49610 $ 1,187.84 $ 1,187.84 90 9% 81% 10% 0 2 0 2 1 0 R Y

49611 $ 1,023.39 $ 1,023.39 90 9% 81% 10% 0 2 0 2 1 0 R Y

49650 $ 772.28 $ 772.28 90 9% 81% 10% 0 2 1 2 1 0 R

49651 $ 1,003.15 $ 1,003.15 90 9% 81% 10% 0 2 1 2 1 0 R

49652 $ 1,336.47 $ 1,336.47 90 9% 81% 10% 0 2 1 2 1 0 R Y-UR

49653 $ 1,666.64 $ 1,666.64 90 9% 81% 10% 0 2 1 2 1 0 R Y-UR

49654 $ 1,518.63 $ 1,518.63 90 9% 81% 10% 0 2 1 2 1 0 R Y-UR

49655 $ 1,852.59 $ 1,852.59 90 9% 81% 10% 0 2 1 2 1 0 R Y-UR

49656 $ 1,646.40 $ 1,646.40 90 9% 81% 10% 0 2 1 2 1 0 R Y-UR

49657 $ 2,368.08 $ 2,368.08 90 9% 81% 10% 0 2 1 2 1 0 R Y-UR


49900 $ 1,471.20 $ 1,471.20 90 9% 81% 10% 0 2 0 2 1 0 R

49904 $ 2,567.95 $ 2,567.95 90 10% 80% 10% 0 2 0 1 1 1 R

49905 $ 633.77 $ 633.77 0 0% 0% 0% 0 0 0 2 2 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY




50010 $ 1,343.43 $ 1,343.43 90 8% 83% 9% 0 2 1 2 1 0 R

50020 $ 1,855.76 $ 1,855.76 90 8% 83% 9% 0 2 0 1 1 0 R

50040 $ 1,692.57 $ 1,692.57 90 8% 83% 9% 0 2 1 1 1 0 R

50045 $ 1,714.08 $ 1,714.08 90 8% 83% 9% 0 2 1 2 1 0 R





50080 $ 1,589.47 $ 1,589.47 90 8% 83% 9% 0 2 1 1 0 0 R Y

50081 $ 2,331.40 $ 2,331.40 90 8% 83% 9% 0 2 1 2 1 0 R Y


50120 $ 1,755.82 $ 1,755.82 90 8% 83% 9% 0 2 1 2 1 0 R

50125 $ 1,871.57 $ 1,871.57 90 8% 83% 9% 0 2 1 2 1 0 R


50135 $ 2,049.30 $ 2,049.30 90 8% 83% 9% 0 2 1 2 1 0 R

50200 $ 1,001.88 $ 237.82 0 0% 0% 0% 0 2 1 1 0 0 R Y

50205 $ 1,356.71 $ 1,356.71 90 8% 83% 9% 0 2 1 2 1 0 R Y

50220 $ 1,903.83 $ 1,903.83 90 8% 83% 9% 0 2 1 2 1 0 R

50225 $ 2,187.82 $ 2,187.82 90 8% 83% 9% 0 2 1 2 1 0 R

50230 $ 2,337.72 $ 2,337.72 90 8% 83% 9% 0 2 1 2 2 0 R

50234 $ 2,374.41 $ 2,374.41 90 8% 83% 9% 0 2 1 2 1 0 R

50236 $ 2,679.27 $ 2,679.27 90 8% 83% 9% 0 2 1 2 1 0 R

50240 $ 2,416.78 $ 2,416.78 90 8% 83% 9% 0 2 1 2 1 0 R




50300 $ 3,654.69 $ 3,654.69 0 0% 0% 0% 9 9 9 9 9 9 F Y

50320 $ 2,709.00 $ 2,709.00 90 8% 83% 9% 0 2 1 2 1 0 R Y



50327 $ 388.36 $ 388.36 0 0% 0% 0% 0 2 0 2 1 0 R Y

50328 $ 340.29 $ 340.29 0 0% 0% 0% 0 2 0 2 1 0 R Y

50329 $ 321.94 $ 321.94 0 0% 0% 0% 0 2 0 2 1 0 R Y

50340 $ 1,705.85 $ 1,705.85 90 8% 83% 9% 0 2 1 2 1 0 R Y

50360 $ 4,344.64 $ 4,344.64 90 8% 83% 9% 0 2 0 2 2 2 R Y

50365 $ 5,143.49 $ 5,143.49 90 8% 83% 9% 0 2 1 2 2 2 R Y

50370 $ 2,166.95 $ 2,166.95 90 8% 83% 9% 0 2 0 2 1 0 R Y

50380 $ 3,466.10 $ 3,466.10 90 8% 83% 9% 0 2 0 2 1 0 R Y

50382 $ 2,074.60 $ 472.48 0 0% 0% 0% 0 2 1 1 0 0 R

50384 $ 1,624.89 $ 426.31 0 0% 0% 0% 0 2 1 1 0 0 R

50385 $ 2,023.37 $ 402.27 0 0% 0% 0% 0 2 1 0 0 0 R

50386 $ 1,287.14 $ 299.81 0 0% 0% 0% 0 2 1 0 0 0 R

50387 $ 919.66 $ 155.60 0 0% 0% 0% 0 2 1 0 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


50389 $ 557.23 $ 99.30 0 0% 0% 0% 0 2 1 1 0 0 R

50390 $ 176.47 $ 176.47 0 0% 0% 0% 0 2 1 1 0 0 R Y

50391 $ 222.64 $ 178.37 0 0% 0% 0% 0 2 1 1 0 0 R Y

50395 $ 327.00 $ 327.00 0 0% 0% 0% 0 2 1 1 0 0 R

50396 $ 215.68 $ 215.68 0 0% 0% 0% 0 2 1 0 0 0 R

50400 $ 2,115.71 $ 2,115.71 90 8% 83% 9% 0 2 1 2 1 0 R Y

50405 $ 2,552.77 $ 2,552.77 90 8% 83% 9% 0 2 1 2 1 0 R Y

50430 $ 850.71 $ 283.36 0 0% 0% 0% 0 2 1 1 0 0 R

50431 $ 302.97 $ 122.71 0 0% 0% 0% 0 2 1 1 0 0 R

50432 $ 1,442.10 $ 382.03 0 0% 0% 0% 0 2 1 1 0 0 R

50433 $ 1,975.30 $ 475.64 0 0% 0% 0% 0 2 1 1 0 0 R

50434 $ 1,551.52 $ 359.89 0 0% 0% 0% 0 2 1 1 0 0 R

50435 $ 883.60 $ 186.59 0 0% 0% 0% 0 2 1 1 0 0 R

50500 $ 2,115.08 $ 2,115.08 90 8% 83% 9% 0 2 0 2 1 0 R

50520 $ 1,883.59 $ 1,883.59 90 8% 83% 9% 0 2 0 2 1 0 R Y

50525 $ 2,829.81 $ 2,829.81 90 8% 83% 9% 0 2 0 2 1 0 R Y

50526 $ 2,670.42 $ 2,670.42 90 8% 83% 9% 0 2 0 2 0 0 R Y




50543 $ 2,717.22 $ 2,717.22 90 8% 83% 9% 0 2 1 2 1 0 R

50544 $ 2,275.10 $ 2,275.10 90 8% 83% 9% 0 2 1 2 1 0 R Y

50545 $ 2,445.88 $ 2,445.88 90 8% 83% 9% 0 2 1 2 1 0 R

50546 $ 2,194.78 $ 2,194.78 90 8% 83% 9% 0 2 1 2 1 0 R

50547 $ 2,902.54 $ 2,902.54 90 8% 83% 9% 0 2 1 2 1 0 R Y

50548 $ 2,459.16 $ 2,459.16 90 8% 83% 9% 0 2 1 2 1 0 R Y


50551 $ 660.33 $ 538.26 0 0% 0% 0% 0 2 1 0 0 0 R

50553 $ 703.97 $ 572.41 0 0% 0% 0% 0 2 1 1 0 0 R

50555 $ 755.84 $ 623.65 0 0% 0% 0% 0 3 1 0 0 0 50551 R

50557 $ 769.75 $ 633.13 0 0% 0% 0% 0 3 1 0 0 0 50551 R

50561 $ 870.32 $ 719.79 0 0% 0% 0% 0 3 1 0 0 0 50551 R


50570 $ 900.05 $ 900.05 0 0% 0% 0% 0 2 1 0 0 0 R

50572 $ 971.52 $ 971.52 0 0% 0% 0% 0 3 1 0 0 0 50570 R

50574 $ 1,032.87 $ 1,032.87 0 0% 0% 0% 0 3 1 0 0 0 50570 R

50575 $ 1,304.85 $ 1,304.85 0 0% 0% 0% 0 3 1 1 0 0 50570 R

50576 $ 1,029.71 $ 1,029.71 0 0% 0% 0% 0 3 1 0 0 0 50570 R

50580 $ 1,110.04 $ 1,110.04 0 0% 0% 0% 0 3 1 0 0 0 50570 R

50590 $ 1,323.82 $ 1,039.83 90 8% 83% 9% 0 2 1 1 0 0 R Y



50600 $ 1,719.77 $ 1,719.77 90 8% 83% 9% 0 2 1 2 1 0 R

50605 $ 1,778.59 $ 1,778.59 90 8% 83% 9% 0 2 1 2 1 0 R

50606 $ 1,315.60 $ 286.52 0 0% 0% 0% 0 0 1 1 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


50610 $ 1,769.10 $ 1,769.10 90 8% 83% 9% 0 2 1 2 1 0 R Y

50620 $ 1,650.19 $ 1,650.19 90 8% 83% 9% 0 2 1 2 1 0 R Y

50630 $ 1,640.71 $ 1,640.71 90 8% 83% 9% 0 2 1 2 1 0 R Y

50650 $ 1,891.18 $ 1,891.18 90 8% 83% 9% 0 2 1 2 1 0 R Y

50660 $ 2,113.18 $ 2,113.18 90 8% 83% 9% 0 2 0 2 1 0 R Y

50684 $ 197.97 $ 93.61 0 0% 0% 0% 0 2 1 1 0 0 R

50686 $ 271.34 $ 164.45 0 0% 0% 0% 0 2 0 0 0 0 R

50688 $ 146.74 $ 146.74 10 10% 80% 10% 0 2 0 1 0 0 R

50690 $ 182.16 $ 130.30 0 0% 0% 0% 0 2 0 1 0 0 R

50693 $ 1,849.43 $ 377.60 0 0% 0% 0% 0 2 1 1 0 0 R Y

50694 $ 2,025.27 $ 493.98 0 0% 0% 0% 0 2 1 1 0 0 R Y

50695 $ 2,485.09 $ 633.13 0 0% 0% 0% 0 2 1 1 0 0 R Y

50700 $ 1,688.78 $ 1,688.78 90 8% 83% 9% 0 2 1 2 1 0 R

50705 $ 3,641.30 $ 364.95 0 0% 0% 0% 0 0 1 1 0 0 R Y

50706 $ 1,869.04 $ 344.08 0 0% 0% 0% 0 0 1 1 0 0 R Y

50715 $ 2,206.79 $ 2,206.79 90 8% 83% 9% 0 2 1 2 1 0 R Y



50727 $ 931.67 $ 931.67 90 8% 83% 9% 0 2 0 2 2 0 R Y

50728 $ 1,278.28 $ 1,278.28 90 8% 83% 9% 0 2 0 2 2 0 R Y

50740 $ 2,176.43 $ 2,176.43 90 8% 83% 9% 0 2 1 2 1 0 R Y

50750 $ 2,099.27 $ 2,099.27 90 8% 83% 9% 0 2 1 2 0 0 R Y

50760 $ 2,045.51 $ 2,045.51 90 8% 83% 9% 0 2 1 2 1 0 R Y

50770 $ 2,137.22 $ 2,137.22 90 8% 83% 9% 0 2 0 2 1 0 R Y

50780 $ 2,017.04 $ 2,017.04 90 8% 83% 9% 0 2 1 2 1 0 R Y

50782 $ 2,141.01 $ 2,141.01 90 8% 83% 9% 0 2 1 2 2 0 R Y

50783 $ 2,067.01 $ 2,067.01 90 8% 83% 9% 0 2 1 2 2 0 R Y

50785 $ 2,213.12 $ 2,213.12 90 8% 83% 9% 0 2 1 2 1 0 R Y

50800 $ 1,687.51 $ 1,687.51 90 8% 83% 9% 0 2 1 2 1 0 R Y

50810 $ 2,463.59 $ 2,463.59 90 8% 83% 9% 0 2 0 2 1 0 R Y

50815 $ 2,239.68 $ 2,239.68 90 8% 83% 9% 0 2 1 2 1 0 R Y

50820 $ 2,398.44 $ 2,398.44 90 8% 83% 9% 0 2 1 2 1 0 R Y

50825 $ 3,024.62 $ 3,024.62 90 8% 83% 9% 0 2 0 2 1 0 R Y

50830 $ 3,313.04 $ 3,313.04 90 8% 83% 9% 0 2 0 2 1 0 R Y

50840 $ 2,249.17 $ 2,249.17 90 8% 83% 9% 0 2 1 2 1 0 R Y

50845 $ 2,285.86 $ 2,285.86 90 8% 83% 9% 0 2 0 2 1 0 R Y

50860 $ 1,739.38 $ 1,739.38 90 8% 83% 9% 0 2 1 2 1 0 R Y

50900 $ 1,563.54 $ 1,563.54 90 8% 83% 9% 0 2 1 2 1 0 R

50920 $ 1,672.33 $ 1,672.33 90 8% 83% 9% 0 2 0 2 1 0 R Y

50930 $ 2,015.78 $ 2,015.78 90 8% 83% 9% 0 2 0 2 1 0 R Y

50940 $ 1,616.67 $ 1,616.67 90 8% 83% 9% 0 2 1 2 1 0 R


50947 $ 2,533.16 $ 2,533.16 90 8% 83% 9% 0 2 1 2 1 0 R Y

50948 $ 2,330.13 $ 2,330.13 90 8% 83% 9% 0 2 1 2 1 0 R Y




Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


50951 $ 689.43 $ 560.40 0 0% 0% 0% 0 2 1 0 0 0 R Y

50953 $ 728.64 $ 595.18 0 0% 0% 0% 0 3 1 0 0 0 50951 R Y

50955 $ 779.87 $ 644.52 0 0% 0% 0% 0 3 1 0 0 0 50951 R Y

50957 $ 787.46 $ 648.31 0 0% 0% 0% 0 3 1 0 0 0 50951 R Y

50961 $ 709.67 $ 579.37 0 0% 0% 0% 0 3 1 0 0 0 50951 R Y

50970 $ 676.78 $ 676.78 0 0% 0% 0% 0 2 1 0 0 0 R Y

50972 $ 654.64 $ 654.64 0 0% 0% 0% 0 2 1 0 0 0 R Y

50974 $ 864.00 $ 864.00 0 0% 0% 0% 0 3 1 0 0 0 50970 R Y

50976 $ 851.98 $ 851.98 0 0% 0% 0% 0 3 1 0 0 0 50970 R Y

50980 $ 650.21 $ 650.21 0 0% 0% 0% 0 2 1 0 0 0 R Y

51020 $ 860.83 $ 860.83 90 8% 83% 9% 0 2 0 2 1 0 R

51030 $ 862.73 $ 862.73 90 8% 83% 9% 0 2 0 0 0 0 R Y

51040 $ 531.93 $ 531.93 90 8% 83% 9% 0 2 0 2 1 0 R

51045 $ 891.83 $ 891.83 90 8% 83% 9% 0 2 0 2 0 0 R




51080 $ 752.68 $ 752.68 90 8% 83% 9% 0 2 0 2 1 0 R

51100 $ 113.22 $ 70.84 0 0% 0% 0% 0 2 0 1 0 0 R

51101 $ 228.97 $ 94.24 0 0% 0% 0% 0 2 0 1 0 0 R

51102 $ 417.45 $ 264.39 0 0% 0% 0% 0 2 0 1 0 0 R

51500 $ 1,168.23 $ 1,168.23 90 8% 83% 9% 0 2 0 2 1 0 R

51520 $ 1,090.43 $ 1,090.43 90 8% 83% 9% 0 2 0 2 1 0 R Y

51525 $ 1,569.87 $ 1,569.87 90 8% 83% 9% 0 2 0 2 1 0 R Y


51535 $ 1,427.55 $ 1,427.55 90 8% 83% 9% 0 2 1 2 1 0 R

51550 $ 1,757.09 $ 1,757.09 90 8% 83% 9% 0 2 0 2 1 0 R

51555 $ 2,310.52 $ 2,310.52 90 8% 83% 9% 0 2 0 2 1 0 R

51565 $ 2,371.88 $ 2,371.88 90 8% 83% 9% 0 2 0 2 1 0 R

51570 $ 2,696.98 $ 2,696.98 90 8% 83% 9% 0 2 0 2 1 0 R


51580 $ 3,503.42 $ 3,503.42 90 8% 83% 9% 0 2 0 2 1 0 R


51590 $ 3,526.82 $ 3,526.82 90 8% 83% 9% 0 2 0 2 1 0 R


51596 $ 4,294.68 $ 4,294.68 90 8% 83% 9% 0 2 0 2 1 0 R


51600 $ 343.45 $ 80.96 0 0% 0% 0% 0 2 0 1 0 0 R

51605 $ 70.84 $ 70.84 0 0% 0% 0% 0 2 0 1 0 0 R

51610 $ 197.34 $ 118.91 0 0% 0% 0% 0 2 0 1 0 0 R

51700 $ 134.72 $ 66.41 0 0% 0% 0% 0 2 0 1 0 0 R

51701 $ 87.29 $ 46.81 0 0% 0% 0% 0 2 0 1 0 0 R

51702 $ 116.38 $ 46.81 0 0% 0% 0% 0 2 0 1 0 0 R

51703 $ 229.60 $ 139.78 0 0% 0% 0% 0 2 0 1 0 0 R

51705 $ 167.61 $ 94.88 0 0% 0% 0% 0 2 0 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


51710 $ 237.19 $ 146.74 0 0% 0% 0% 0 2 0 1 0 0 R

51715 $ 533.83 $ 364.32 0 0% 0% 0% 0 2 0 0 0 0 R


51725 $ 347.24 $ 347.24 0 0% 0% 0% 1 2 0 0 0 0 R

51725-26 $ 139.15 $ 139.15 0 0% 0% 0% 1 2 0 0 0 0 R

51725-TC $ 207.46 $ 207.46 0 0% 0% 0% 1 2 0 0 0 0 R

51726 $ 490.82 $ 490.82 0 0% 0% 0% 1 2 0 1 0 0 R

51726-26 $ 155.60 $ 155.60 0 0% 0% 0% 1 2 0 1 0 0 R

51726-TC $ 334.59 $ 334.59 0 0% 0% 0% 1 2 0 1 0 0 R

51727 $ 579.37 $ 579.37 0 0% 0% 0% 1 2 0 0 0 0 R

51727-26 $ 196.08 $ 196.08 0 0% 0% 0% 1 2 0 0 0 0 R

51727-TC $ 383.30 $ 383.30 0 0% 0% 0% 1 2 0 0 0 0 R

51728 $ 586.33 $ 586.33 0 0% 0% 0% 1 2 0 0 0 0 R

51728-26 $ 191.65 $ 191.65 0 0% 0% 0% 1 2 0 0 0 0 R

51728-TC $ 394.68 $ 394.68 0 0% 0% 0% 1 2 0 0 0 0 R

51729 $ 631.87 $ 631.87 0 0% 0% 0% 1 2 0 0 0 0 R

51729-26 $ 231.50 $ 231.50 0 0% 0% 0% 1 2 0 0 0 0 R

51729-TC $ 401.01 $ 401.01 0 0% 0% 0% 1 2 0 0 0 0 R

51736 $ 28.46 $ 28.46 0 0% 0% 0% 1 2 0 0 0 0 R

51736-26 $ 15.18 $ 15.18 0 0% 0% 0% 1 2 0 0 0 0 R

51736-TC $ 13.28 $ 13.28 0 0% 0% 0% 1 2 0 0 0 0 R

51741 $ 29.10 $ 29.10 0 0% 0% 0% 1 2 0 1 0 0 R

51741-26 $ 15.18 $ 15.18 0 0% 0% 0% 1 2 0 1 0 0 R

51741-TC $ 13.92 $ 13.92 0 0% 0% 0% 1 2 0 1 0 0 R

51784 $ 127.77 $ 127.77 0 0% 0% 0% 1 2 0 1 0 0 R

51784-26 $ 68.31 $ 68.31 0 0% 0% 0% 1 2 0 1 0 0 R

51784-TC $ 58.82 $ 58.82 0 0% 0% 0% 1 2 0 1 0 0 R

51785 $ 487.66 $ 487.66 0 0% 0% 0% 1 2 0 0 0 0 R

51785-26 $ 158.13 $ 158.13 0 0% 0% 0% 1 2 0 0 0 0 R

51785-TC $ 329.53 $ 329.53 0 0% 0% 0% 1 2 0 0 0 0 R

51792 $ 394.68 $ 394.68 0 0% 0% 0% 1 2 0 0 0 0 R

51792-26 $ 100.57 $ 100.57 0 0% 0% 0% 1 2 0 0 0 0 R

51792-TC $ 294.11 $ 294.11 0 0% 0% 0% 1 2 0 0 0 0 R

51797 $ 208.09 $ 208.09 0 0% 0% 0% 1 0 0 0 0 0 R

51797-26 $ 73.37 $ 73.37 0 0% 0% 0% 1 0 0 0 0 0 R

51797-TC $ 134.72 $ 134.72 0 0% 0% 0% 1 0 0 0 0 0 R

51798 $ 36.05 $ 36.05 0 0% 0% 0% 3 0 0 0 0 0 R

51800 $ 1,909.52 $ 1,909.52 90 8% 83% 9% 0 2 0 2 1 0 R Y

51820 $ 2,122.04 $ 2,122.04 90 8% 83% 9% 0 2 2 2 1 0 R Y

51840 $ 1,199.22 $ 1,199.22 90 8% 83% 9% 0 2 0 2 1 0 R Y

51841 $ 1,426.29 $ 1,426.29 90 8% 83% 9% 0 2 0 2 1 0 R Y

51845 $ 1,067.03 $ 1,067.03 90 8% 83% 9% 0 2 0 2 1 0 R Y

51860 $ 1,356.71 $ 1,356.71 90 8% 83% 9% 0 2 0 2 1 0 R

51865 $ 1,631.85 $ 1,631.85 90 8% 83% 9% 0 2 0 2 1 0 R

51880 $ 854.51 $ 854.51 90 8% 83% 9% 0 2 0 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


51900 $ 1,530.65 $ 1,530.65 90 8% 83% 9% 0 2 0 2 1 0 R Y

51920 $ 1,423.13 $ 1,423.13 90 8% 83% 9% 0 2 0 2 1 0 R Y

51925 $ 1,880.42 $ 1,880.42 90 8% 83% 9% 0 2 0 2 1 0 R Y


51960 $ 2,531.90 $ 2,531.90 90 8% 83% 9% 0 2 0 2 1 0 R Y

51980 $ 1,306.11 $ 1,306.11 90 8% 83% 9% 0 2 0 2 1 0 R Y

51990 $ 1,371.89 $ 1,371.89 90 8% 83% 9% 0 2 0 2 1 0 R Y

51992 $ 1,531.28 $ 1,531.28 90 8% 83% 9% 0 2 0 2 1 0 R Y


52000 $ 303.60 $ 187.85 0 0% 0% 0% 0 2 0 1 0 0 R

52001 $ 681.20 $ 524.98 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52005 $ 492.09 $ 244.15 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52007 $ 825.41 $ 303.60 0 0% 0% 0% 0 3 1 1 0 0 52000 R Y

52010 $ 681.20 $ 303.60 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52204 $ 685.63 $ 259.33 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52214 $ 1,232.11 $ 321.94 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52224 $ 1,288.40 $ 371.91 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52234 $ 450.34 $ 450.34 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52235 $ 527.51 $ 527.51 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52240 $ 715.99 $ 715.99 0 0% 0% 0% 0 3 0 1 0 0 52000 R


52260 $ 384.56 $ 384.56 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52265 $ 677.41 $ 297.28 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52270 $ 657.80 $ 333.33 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52275 $ 886.77 $ 454.77 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52276 $ 483.86 $ 483.86 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52277 $ 590.76 $ 590.76 0 0% 0% 0% 0 3 0 0 0 0 52000 R

52281 $ 503.47 $ 278.93 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52282 $ 614.79 $ 614.79 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52283 $ 508.53 $ 368.12 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52285 $ 513.59 $ 358.00 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52287 $ 574.31 $ 309.29 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52290 $ 445.91 $ 445.91 0 0% 0% 0% 0 3 2 1 0 0 52000 R

52300 $ 512.33 $ 512.33 0 0% 0% 0% 0 3 2 0 0 0 52000 R Y

52301 $ 530.04 $ 530.04 0 0% 0% 0% 0 3 2 0 0 0 52000 R Y

52305 $ 509.80 $ 509.80 0 0% 0% 0% 0 3 0 1 0 0 52000 R Y

52310 $ 447.81 $ 277.04 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52315 $ 758.37 $ 501.57 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52317 $ 1,490.17 $ 634.40 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52318 $ 864.63 $ 864.63 0 0% 0% 0% 0 3 0 1 0 0 52000 R

52320 $ 450.97 $ 450.97 0 0% 0% 0% 0 3 1 1 0 0 52000 R

52325 $ 586.33 $ 586.33 0 0% 0% 0% 0 3 1 1 0 0 52000 R

52327 $ 477.54 $ 477.54 0 0% 0% 0% 0 3 1 1 0 0 52000 R

52330 $ 912.07 $ 481.97 0 0% 0% 0% 0 3 1 1 0 0 52000 R

52332 $ 912.70 $ 285.26 0 0% 0% 0% 0 3 1 1 0 0 52000 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


52334 $ 467.42 $ 467.42 0 0% 0% 0% 0 3 1 1 0 0 52000 R

52341 $ 519.28 $ 519.28 0 0% 0% 0% 0 3 1 1 0 0 52000 R

52342 $ 565.46 $ 565.46 0 0% 0% 0% 0 3 1 1 0 0 52000 R

52343 $ 628.71 $ 628.71 0 0% 0% 0% 0 3 1 1 0 0 52000 R

52344 $ 674.88 $ 674.88 0 0% 0% 0% 0 3 1 1 0 0 52000 R

52345 $ 720.42 $ 720.42 0 0% 0% 0% 0 3 1 0 0 0 52351 R

52346 $ 815.29 $ 815.29 0 0% 0% 0% 0 3 1 0 0 0 52351 R

52351 $ 553.44 $ 553.44 0 0% 0% 0% 0 2 0 1 0 0 R

52352 $ 647.05 $ 647.05 0 0% 0% 0% 0 3 1 1 0 0 52351 R Y

52353 $ 715.99 $ 715.99 0 0% 0% 0% 0 3 1 1 0 0 52351 R Y

52354 $ 762.16 $ 762.16 0 0% 0% 0% 0 3 1 1 0 0 52351 R Y


52356 $ 759.63 $ 759.63 0 0% 0% 0% 0 3 1 1 0 0 52351 R Y

52400 $ 874.12 $ 874.12 90 8% 83% 9% 0 3 0 1 0 0 52000 R Y

52402 $ 486.39 $ 486.39 0 0% 0% 0% 0 3 0 1 0 0 52000 R Y

52441 $ 2,323.81 $ 413.02 0 0% 0% 0% 0 3 0 1 0 0 43235 R Y

52442 $ 1,789.98 $ 110.06 0 0% 0% 0% 0 0 0 1 0 0 R Y

52450 $ 862.10 $ 862.10 90 8% 83% 9% 0 2 0 1 0 0 R

52500 $ 894.36 $ 894.36 90 8% 83% 9% 0 2 0 1 0 0 R

52601 $ 1,545.83 $ 1,545.83 90 8% 83% 9% 0 2 0 1 0 0 R Y

52630 $ 734.33 $ 734.33 90 8% 83% 9% 0 2 0 1 0 0 R Y

52640 $ 580.00 $ 580.00 90 8% 83% 9% 0 2 0 1 0 0 R Y

52647 $ 3,318.10 $ 1,184.67 90 8% 83% 9% 0 2 0 1 0 0 R Y

52648 $ 3,411.71 $ 1,262.47 90 8% 83% 9% 0 2 0 1 0 0 R Y

52649 $ 1,505.98 $ 1,505.98 90 8% 83% 9% 0 2 0 0 0 0 R Y

52700 $ 810.23 $ 810.23 90 8% 83% 9% 0 2 0 0 0 0 R

53000 $ 271.34 $ 271.34 10 10% 80% 10% 0 2 0 1 0 0 R

53010 $ 542.69 $ 542.69 90 8% 83% 9% 0 2 0 1 0 0 R

53020 $ 177.73 $ 177.73 0 0% 0% 0% 0 2 0 1 0 0 R


53040 $ 719.79 $ 719.79 90 8% 83% 9% 0 2 0 0 0 0 R

53060 $ 336.49 $ 301.07 10 10% 80% 10% 0 2 0 1 0 0 R

53080 $ 770.39 $ 770.39 90 8% 83% 9% 0 2 0 1 0 0 R

53085 $ 1,202.38 $ 1,202.38 90 8% 83% 9% 0 2 0 2 1 0 R

53200 $ 284.63 $ 259.96 0 0% 0% 0% 0 2 0 1 0 0 R Y




53230 $ 1,109.41 $ 1,109.41 90 8% 83% 9% 0 2 0 2 1 0 R Y

53235 $ 1,160.01 $ 1,160.01 90 8% 83% 9% 0 2 0 2 1 0 R Y

53240 $ 779.24 $ 779.24 90 8% 83% 9% 0 2 0 1 0 0 R Y

53250 $ 750.78 $ 750.78 90 8% 83% 9% 0 2 0 1 0 0 R Y






Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY



53400 $ 1,464.24 $ 1,464.24 90 8% 83% 9% 0 2 0 2 1 0 R Y

53405 $ 1,605.29 $ 1,605.29 90 8% 83% 9% 0 2 0 2 1 0 R Y

53410 $ 1,786.81 $ 1,786.81 90 8% 83% 9% 0 2 0 2 1 0 R Y

53415 $ 2,064.48 $ 2,064.48 90 8% 83% 9% 0 2 0 2 1 0 R Y

53420 $ 1,537.61 $ 1,537.61 90 8% 83% 9% 0 2 0 1 1 0 R Y

53425 $ 1,711.55 $ 1,711.55 90 8% 83% 9% 0 2 0 2 1 0 R Y

53430 $ 1,765.31 $ 1,765.31 90 8% 83% 9% 0 2 0 2 1 0 R Y

53431 $ 2,108.12 $ 2,108.12 90 8% 83% 9% 0 2 0 2 1 0 R Y

53440 $ 1,376.95 $ 1,376.95 90 8% 83% 9% 0 2 0 2 1 0 R Y

53442 $ 1,433.25 $ 1,433.25 90 8% 83% 9% 0 2 0 2 0 0 R Y

53444 $ 1,449.06 $ 1,449.06 90 8% 83% 9% 0 2 0 2 1 0 R Y

53445 $ 1,378.85 $ 1,378.85 90 8% 83% 9% 0 2 0 2 1 0 R Y

53446 $ 1,175.82 $ 1,175.82 90 8% 83% 9% 0 2 0 2 1 0 R Y

53447 $ 1,478.79 $ 1,478.79 90 8% 83% 9% 0 2 0 2 1 0 R Y

53448 $ 2,339.62 $ 2,339.62 90 8% 83% 9% 0 2 0 2 1 0 R Y

53449 $ 1,119.53 $ 1,119.53 90 8% 83% 9% 0 2 0 2 1 0 R Y

53450 $ 749.51 $ 749.51 90 8% 83% 9% 0 2 0 1 0 0 R

53460 $ 839.33 $ 839.33 90 8% 83% 9% 0 2 0 0 0 0 R

53500 $ 1,368.10 $ 1,368.10 90 12% 74% 14% 0 2 0 2 1 0 R Y

53502 $ 891.19 $ 891.19 90 8% 83% 9% 0 2 0 1 0 0 R

53505 $ 889.93 $ 889.93 90 8% 83% 9% 0 2 0 2 0 0 R

53510 $ 1,155.58 $ 1,155.58 90 8% 83% 9% 0 2 0 2 1 0 R

53515 $ 1,444.63 $ 1,444.63 90 8% 83% 9% 0 2 0 2 1 0 R

53520 $ 1,018.96 $ 1,018.96 90 8% 83% 9% 0 2 0 1 0 0 R Y

53600 $ 152.43 $ 116.38 0 0% 0% 0% 0 2 0 1 0 0 R

53601 $ 149.27 $ 98.04 0 0% 0% 0% 0 2 0 1 0 0 R

53605 $ 117.65 $ 117.65 0 0% 0% 0% 0 2 0 1 0 0 R

53620 $ 213.15 $ 160.02 0 0% 0% 0% 0 2 0 1 0 0 R

53621 $ 200.50 $ 132.19 0 0% 0% 0% 0 2 0 1 0 0 R

53660 $ 130.30 $ 76.53 0 0% 0% 0% 0 2 0 1 0 0 R

53661 $ 128.40 $ 74.00 0 0% 0% 0% 0 2 0 1 0 0 R

53665 $ 70.21 $ 70.21 0 0% 0% 0% 0 2 0 1 0 0 R








54015 $ 563.56 $ 563.56 10 10% 80% 10% 0 2 0 0 0 0 R

54050 $ 244.78 $ 195.44 10 10% 80% 10% 0 2 0 1 0 0 R Y

54055 $ 218.85 $ 170.78 10 10% 80% 10% 0 2 0 1 0 0 R Y

54056 $ 261.86 $ 204.93 10 10% 80% 10% 0 2 0 1 0 0 R Y

54057 $ 252.37 $ 175.20 10 10% 80% 10% 0 2 0 1 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


54060 $ 330.80 $ 239.72 10 10% 80% 10% 0 2 0 1 0 0 R Y

54065 $ 402.27 $ 317.52 10 10% 80% 10% 0 2 0 1 0 0 R Y

54100 $ 366.22 $ 231.50 0 0% 0% 0% 0 2 0 1 0 0 R Y

54105 $ 485.13 $ 390.89 10 10% 80% 10% 0 2 0 1 0 0 R Y




54115 $ 834.90 $ 784.30 90 10% 80% 10% 0 2 0 2 0 0 R

54120 $ 1,156.84 $ 1,156.84 90 10% 80% 10% 0 2 0 2 1 0 R Y

54125 $ 1,488.27 $ 1,488.27 90 10% 80% 10% 0 2 0 2 1 0 R Y





54161 $ 360.53 $ 360.53 10 10% 80% 10% 0 2 0 1 0 0 R Y






54220 $ 376.34 $ 244.78 0 0% 0% 0% 0 2 0 1 0 0 R

54230 $ 177.10 $ 146.11 0 0% 0% 0% 0 2 0 1 0 0 R

54231 $ 256.80 $ 213.79 0 0% 0% 0% 0 2 0 1 0 0 R

54235 $ 166.35 $ 134.72 0 0% 0% 0% 0 2 0 1 0 0 R

54240 $ 189.12 $ 189.12 0 0% 0% 0% 1 0 0 0 0 0 R

54240-26 $ 123.34 $ 123.34 0 0% 0% 0% 1 0 0 0 0 0 R

54240-TC $ 65.78 $ 65.78 0 0% 0% 0% 1 0 0 0 0 0 R

54250 $ 221.38 $ 221.38 0 0% 0% 0% 1 0 0 0 0 0 R

54250-26 $ 200.50 $ 200.50 0 0% 0% 0% 1 0 0 0 0 0 R

54250-TC $ 20.24 $ 20.24 0 0% 0% 0% 1 0 0 0 0 0 R


















Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY







54400 $ 968.99 $ 968.99 90 10% 80% 10% 0 2 0 1 1 0 R Y

54401 $ 1,203.65 $ 1,203.65 90 10% 80% 10% 0 2 0 1 1 0 R Y

54405 $ 1,478.15 $ 1,478.15 90 10% 80% 10% 0 2 0 2 1 0 R Y

54406 $ 1,336.47 $ 1,336.47 90 10% 80% 10% 0 2 0 2 1 0 R Y

54408 $ 1,446.53 $ 1,446.53 90 10% 80% 10% 0 2 0 2 1 0 R Y

54410 $ 1,572.40 $ 1,572.40 90 10% 80% 10% 0 2 0 2 1 0 R Y

54411 $ 1,876.63 $ 1,876.63 90 10% 80% 10% 0 2 0 2 1 0 R Y

54415 $ 968.99 $ 968.99 90 10% 80% 10% 0 2 0 2 1 0 R Y

54416 $ 1,302.32 $ 1,302.32 90 10% 80% 10% 0 2 0 2 1 0 R Y

54417 $ 1,643.24 $ 1,643.24 90 10% 80% 10% 0 2 0 2 1 0 R Y

54420 $ 1,287.77 $ 1,287.77 90 10% 80% 10% 0 2 0 2 0 0 R

54430 $ 1,170.76 $ 1,170.76 90 10% 80% 10% 0 2 2 2 0 0 R

54435 $ 765.96 $ 765.96 90 10% 80% 10% 0 2 0 1 0 0 R

54437 $ 1,241.60 $ 1,241.60 90 10% 80% 10% 0 2 0 2 1 0 R Y

54438 $ 2,450.94 $ 2,450.94 90 8% 83% 9% 0 2 0 2 1 0 R Y



54500 $ 137.25 $ 137.25 0 0% 0% 0% 0 2 1 0 0 0 R Y

54505 $ 385.19 $ 385.19 10 10% 80% 10% 0 2 1 0 0 0 R Y

54512 $ 987.97 $ 987.97 90 10% 80% 10% 0 2 1 1 1 0 R

54520 $ 597.71 $ 597.71 90 10% 80% 10% 0 2 1 1 0 0 R

54522 $ 1,084.11 $ 1,084.11 90 10% 80% 10% 0 2 1 2 1 0 R

54530 $ 925.35 $ 925.35 90 10% 80% 10% 0 2 1 2 1 0 R

54535 $ 1,373.16 $ 1,373.16 90 10% 80% 10% 0 2 1 2 0 0 R Y



54600 $ 833.64 $ 833.64 90 10% 80% 10% 0 2 1 1 0 0 R


54640 $ 876.65 $ 876.65 90 10% 80% 10% 0 2 1 0 0 0 R Y


54660 $ 668.55 $ 668.55 90 10% 80% 10% 0 2 1 0 0 0 R

54670 $ 752.04 $ 752.04 90 10% 80% 10% 0 2 1 0 0 0 R

54680 $ 1,468.03 $ 1,468.03 90 10% 80% 10% 0 2 2 2 1 0 R

54690 $ 1,206.81 $ 1,206.81 90 10% 80% 10% 0 2 1 2 1 0 R



54700 $ 391.52 $ 391.52 10 10% 80% 10% 0 2 1 1 0 0 R

54800 $ 242.88 $ 242.88 0 0% 0% 0% 0 2 1 0 0 0 R Y

54830 $ 684.37 $ 684.37 90 10% 80% 10% 0 2 1 0 0 0 R

54840 $ 589.49 $ 589.49 90 10% 80% 10% 0 2 1 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


54860 $ 768.49 $ 768.49 90 10% 80% 10% 0 2 0 1 0 0 R

54861 $ 1,036.67 $ 1,036.67 90 10% 80% 10% 0 2 0 0 0 0 R

54865 $ 659.07 $ 659.07 90 10% 80% 10% 0 2 0 0 0 0 R Y

54900 $ 1,526.86 $ 1,526.86 90 10% 80% 10% 0 2 0 0 0 0 R Y

54901 $ 1,930.39 $ 1,930.39 90 10% 80% 10% 0 2 2 0 0 0 R Y

55000 $ 215.05 $ 156.23 0 0% 0% 0% 0 2 1 1 0 0 R Y

55040 $ 619.85 $ 619.85 90 10% 80% 10% 0 2 0 1 0 0 R Y

55041 $ 934.84 $ 934.84 90 10% 80% 10% 0 2 2 1 0 0 R Y

55060 $ 698.28 $ 698.28 90 10% 80% 10% 0 2 1 0 0 0 R Y

55100 $ 396.58 $ 304.23 10 10% 80% 10% 0 2 0 1 0 0 R

55110 $ 711.56 $ 711.56 90 10% 80% 10% 0 2 0 1 0 0 R

55120 $ 660.33 $ 660.33 90 10% 80% 10% 0 2 0 0 0 0 R


55175 $ 667.92 $ 667.92 90 10% 80% 10% 0 2 0 0 0 0 R

55180 $ 1,258.68 $ 1,258.68 90 10% 80% 10% 0 2 0 0 0 0 R






55500 $ 722.32 $ 722.32 90 10% 80% 10% 0 2 1 0 0 0 R Y

55520 $ 818.46 $ 818.46 90 10% 80% 10% 0 2 1 2 1 0 R Y

55530 $ 645.15 $ 645.15 90 10% 80% 10% 0 2 1 1 1 0 R

55535 $ 789.36 $ 789.36 90 10% 80% 10% 0 2 1 2 1 0 R

55540 $ 993.66 $ 993.66 90 10% 80% 10% 0 2 1 1 1 0 R

55550 $ 785.57 $ 785.57 90 10% 80% 10% 0 2 1 2 1 0 R


55600 $ 773.55 $ 773.55 90 10% 80% 10% 0 2 1 0 0 0 R Y

55605 $ 998.09 $ 998.09 90 10% 80% 10% 0 2 1 0 0 0 R Y

55650 $ 1,314.34 $ 1,314.34 90 10% 80% 10% 0 2 1 2 1 0 R Y


55700 $ 457.30 $ 239.09 0 0% 0% 0% 0 2 0 1 0 0 R Y

55705 $ 487.66 $ 487.66 10 10% 80% 10% 0 2 0 1 1 0 R Y


55720 $ 827.94 $ 827.94 90 10% 80% 10% 0 2 0 2 1 0 R Y

55725 $ 1,184.04 $ 1,184.04 90 10% 80% 10% 0 2 0 2 1 0 R Y












Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY






55870 $ 321.94 $ 260.59 0 0% 0% 0% 0 2 0 1 1 0 R








56405 $ 198.61 $ 197.34 10 10% 80% 10% 0 2 0 1 2 0 R Y

56420 $ 221.38 $ 165.08 10 10% 80% 10% 0 2 0 1 0 0 R Y






56605 $ 149.90 $ 108.79 0 0% 0% 0% 0 2 0 1 2 0 R Y

56606 $ 68.31 $ 53.76 0 0% 0% 0% 0 0 0 1 2 0 R Y












56800 $ 434.53 $ 434.53 10 10% 80% 10% 0 2 0 2 1 0 R Y


56810 $ 469.32 $ 469.32 10 10% 80% 10% 0 2 0 2 2 0 R Y

56820 $ 203.67 $ 156.23 0 0% 0% 0% 0 2 0 1 0 0 R Y

56821 $ 268.18 $ 208.73 0 0% 0% 0% 0 2 0 1 0 0 R Y

57000 $ 333.33 $ 333.33 10 10% 80% 10% 0 2 0 0 0 0 R Y

57010 $ 785.57 $ 785.57 90 12% 74% 14% 0 2 0 0 0 0 R Y

57020 $ 166.98 $ 144.84 0 0% 0% 0% 0 2 0 0 0 0 R Y

57022 $ 308.66 $ 308.66 10 10% 80% 10% 0 2 0 0 0 0 R Y

57023 $ 557.87 $ 557.87 10 10% 80% 10% 0 2 0 0 0 0 R Y



57100 $ 161.92 $ 120.81 0 0% 0% 0% 0 2 0 1 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


57105 $ 247.94 $ 229.60 10 10% 80% 10% 0 2 0 1 0 0 R Y

57106 $ 891.83 $ 891.83 90 12% 74% 14% 0 2 0 2 1 0 R Y

57107 $ 2,608.43 $ 2,608.43 90 12% 74% 14% 0 2 0 2 1 0 R Y

57109 $ 3,135.30 $ 3,135.30 90 12% 74% 14% 0 2 2 2 1 0 R Y

57110 $ 1,606.55 $ 1,606.55 90 12% 74% 14% 0 2 0 2 1 0 R Y

57111 $ 2,912.03 $ 2,912.03 90 12% 74% 14% 0 2 2 2 1 0 R Y

57112 $ 3,232.08 $ 3,232.08 90 12% 74% 14% 0 2 2 2 1 0 R Y

57120 $ 917.76 $ 917.76 90 12% 74% 14% 0 2 0 2 1 0 R Y

57130 Not Covered Not Covered 10 10% 80% 10% 0 2 0 2 1 0 X 0


57150 $ 82.23 $ 52.50 0 0% 0% 0% 0 2 0 1 0 0 R



57160 $ 139.78 $ 84.76 0 0% 0% 0% 0 2 0 1 0 0 R Y


57180 $ 256.16 $ 191.02 10 10% 80% 10% 0 2 0 1 0 0 R

57200 $ 547.11 $ 547.11 90 12% 74% 14% 0 2 0 2 1 0 R

57210 $ 662.86 $ 662.86 90 12% 74% 14% 0 2 0 2 1 0 R

57220 $ 578.74 $ 578.74 90 12% 74% 14% 0 2 0 2 1 0 R Y

57230 $ 712.83 $ 712.83 90 12% 74% 14% 0 2 0 2 1 0 R Y

57240 $ 1,209.97 $ 1,209.97 90 12% 74% 14% 0 2 0 2 1 0 R Y

57250 $ 1,216.93 $ 1,216.93 90 12% 74% 14% 0 2 0 2 1 0 R Y

57260 $ 1,497.76 $ 1,497.76 90 12% 74% 14% 0 2 0 2 1 0 R Y

57265 $ 1,640.07 $ 1,640.07 90 12% 74% 14% 0 2 0 2 1 0 R Y

57267 $ 460.46 $ 460.46 0 0% 0% 0% 0 0 0 2 1 0 R Y

57268 $ 874.75 $ 874.75 90 12% 74% 14% 0 2 0 2 1 0 R Y

57270 $ 1,440.84 $ 1,440.84 90 12% 74% 14% 0 2 0 2 1 0 R Y

57280 $ 1,716.61 $ 1,716.61 90 12% 74% 14% 0 2 0 2 1 0 R Y

57282 $ 905.11 $ 905.11 90 12% 74% 14% 0 2 0 2 1 0 R Y

57283 $ 1,240.33 $ 1,240.33 90 12% 74% 14% 0 2 0 2 1 0 R Y

57284 $ 1,468.03 $ 1,468.03 90 8% 83% 9% 0 2 0 2 2 0 R Y

57285 $ 1,212.50 $ 1,212.50 90 8% 83% 9% 0 2 0 2 2 0 R Y

57287 $ 1,234.64 $ 1,234.64 90 12% 74% 14% 0 2 0 2 1 0 R Y

57288 $ 1,295.36 $ 1,295.36 90 12% 74% 14% 0 2 0 2 1 0 R Y

57289 $ 1,333.31 $ 1,333.31 90 12% 74% 14% 0 2 0 2 1 0 R Y



57295 $ 862.73 $ 862.73 90 12% 74% 14% 0 2 0 2 1 0 R

57296 $ 1,684.98 $ 1,684.98 90 12% 74% 14% 0 2 0 2 1 0 R Y

57300 $ 1,015.16 $ 1,015.16 90 12% 74% 14% 0 2 0 2 1 0 R Y

57305 $ 1,678.66 $ 1,678.66 90 12% 74% 14% 0 2 0 2 1 0 R Y

57307 $ 1,877.26 $ 1,877.26 90 12% 74% 14% 0 2 0 2 1 0 R Y

57308 $ 1,151.15 $ 1,151.15 90 12% 74% 14% 0 2 0 2 1 0 R Y

57310 $ 845.02 $ 845.02 90 12% 74% 14% 0 2 0 2 1 0 R Y

57311 $ 958.24 $ 958.24 90 12% 74% 14% 0 2 0 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


57320 $ 967.09 $ 967.09 90 12% 74% 14% 0 2 0 2 1 0 R Y

57330 $ 1,364.94 $ 1,364.94 90 12% 74% 14% 0 2 0 2 1 0 R Y



57410 $ 194.81 $ 194.81 0 0% 0% 0% 0 2 0 1 0 0 R Y

57415 $ 289.69 $ 289.69 10 10% 80% 10% 0 2 0 0 0 0 R Y

57420 $ 213.79 $ 165.72 0 0% 0% 0% 0 2 0 1 0 0 R Y

57421 $ 284.63 $ 223.27 0 0% 0% 0% 0 2 0 1 0 0 R Y

57423 $ 1,639.44 $ 1,639.44 90 8% 83% 9% 0 2 0 2 2 0 R Y

57425 $ 1,746.33 $ 1,746.33 90 12% 74% 14% 0 2 0 2 1 0 R Y

57426 $ 1,518.63 $ 1,518.63 90 12% 74% 14% 0 2 0 2 1 0 R Y

57452 $ 197.97 $ 166.98 0 0% 0% 0% 0 2 0 1 0 0 R Y

57454 $ 276.40 $ 245.41 0 0% 0% 0% 0 3 0 1 0 0 57452 R Y

57455 $ 258.69 $ 199.87 0 0% 0% 0% 0 3 0 1 0 0 57452 R Y

57456 $ 244.15 $ 185.96 0 0% 0% 0% 0 3 0 1 0 0 57452 R Y

57460 $ 517.39 $ 293.48 0 0% 0% 0% 0 3 0 1 0 0 57452 R Y

57461 $ 584.43 $ 337.76 0 0% 0% 0% 0 3 0 1 0 0 57452 R Y

57500 $ 234.66 $ 137.89 0 0% 0% 0% 0 2 0 1 0 0 R Y

57505 $ 185.96 $ 168.25 10 10% 80% 10% 0 2 0 1 0 0 R Y








57540 $ 1,498.39 $ 1,498.39 90 12% 74% 14% 0 2 0 2 1 0 R Y

57545 $ 1,495.86 $ 1,495.86 90 12% 74% 14% 0 2 0 2 1 0 R Y

57550 $ 733.07 $ 733.07 90 12% 74% 14% 0 2 0 2 1 0 R Y

57555 $ 1,083.47 $ 1,083.47 90 12% 74% 14% 0 2 0 2 1 0 R Y

57556 $ 1,019.59 $ 1,019.59 90 12% 74% 14% 0 2 0 2 1 0 R Y

57558 $ 225.17 $ 204.93 10 10% 80% 10% 0 2 0 1 0 0 R Y


57720 $ 556.60 $ 556.60 90 12% 74% 14% 0 2 0 2 0 0 R Y

57800 $ 110.06 $ 87.92 0 0% 0% 0% 0 2 0 1 0 0 R Y

58100 $ 197.97 $ 158.13 0 0% 0% 0% 0 2 0 1 0 0 R Y


58120 $ 468.05 $ 394.68 10 10% 80% 10% 0 2 0 1 0 0 R Y




58150 $ 1,823.50 $ 1,823.50 90 12% 74% 14% 0 2 0 2 1 0 R Y

58152 $ 2,242.85 $ 2,242.85 90 12% 74% 14% 0 2 0 2 1 0 R Y

58180 $ 1,729.89 $ 1,729.89 90 12% 74% 14% 0 2 0 2 1 0 R Y

58200 $ 2,461.06 $ 2,461.06 90 12% 74% 14% 0 2 0 2 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


58210 $ 3,312.40 $ 3,312.40 90 12% 74% 14% 0 2 2 2 1 0 R Y


58260 $ 1,484.48 $ 1,484.48 90 12% 74% 14% 0 2 0 2 1 0 R Y

58262 $ 1,655.25 $ 1,655.25 90 12% 74% 14% 0 2 0 2 2 0 R Y

58263 $ 1,776.06 $ 1,776.06 90 12% 74% 14% 0 2 0 2 2 0 R Y

58267 $ 1,884.85 $ 1,884.85 90 12% 74% 14% 0 2 0 2 1 0 R Y

58270 $ 1,583.15 $ 1,583.15 90 12% 74% 14% 0 2 0 2 1 0 R Y

58275 $ 1,767.21 $ 1,767.21 90 12% 74% 14% 0 2 0 2 1 0 R Y

58280 $ 1,884.85 $ 1,884.85 90 12% 74% 14% 0 2 0 2 1 0 R Y


58290 $ 2,063.85 $ 2,063.85 90 12% 74% 14% 0 2 0 2 1 0 R Y

58291 $ 2,227.67 $ 2,227.67 90 12% 74% 14% 0 2 0 2 2 0 R Y

58292 $ 2,349.11 $ 2,349.11 90 12% 74% 14% 0 2 0 2 2 0 R Y

58293 $ 2,444.61 $ 2,444.61 90 12% 74% 14% 0 2 0 2 1 0 R Y

58294 $ 2,179.60 $ 2,179.60 90 12% 74% 14% 0 2 0 2 1 0 R Y












58400 $ 794.42 $ 794.42 90 12% 74% 14% 0 2 0 2 1 0 R Y

58410 $ 1,447.79 $ 1,447.79 90 12% 74% 14% 0 2 0 2 1 0 R Y

58520 $ 1,483.85 $ 1,483.85 90 12% 74% 14% 0 2 0 2 1 0 R Y


58541 $ 1,289.67 $ 1,289.67 90 12% 74% 14% 0 3 0 2 2 0 49320 R Y

58542 $ 1,471.20 $ 1,471.20 90 12% 74% 14% 0 2 0 2 2 0 R Y

58543 $ 1,486.38 $ 1,486.38 90 12% 74% 14% 0 2 0 2 2 0 R Y

58544 $ 1,617.94 $ 1,617.94 90 12% 74% 14% 0 2 0 2 2 0 R Y




58550 $ 1,584.41 $ 1,584.41 90 12% 74% 14% 0 3 0 2 2 0 49320 R Y

58552 $ 1,772.27 $ 1,772.27 90 12% 74% 14% 0 2 0 2 2 0 R Y

58553 $ 2,039.18 $ 2,039.18 90 12% 74% 14% 0 2 0 2 2 0 R Y

58554 $ 2,378.20 $ 2,378.20 90 12% 74% 14% 0 2 0 2 2 0 R Y

58555 $ 491.45 $ 278.30 0 0% 0% 0% 0 2 0 0 2 0 R Y

58558 $ 2,543.28 $ 423.78 0 0% 0% 0% 0 3 0 1 2 0 58555 R Y

58559 $ 522.45 $ 522.45 0 0% 0% 0% 0 3 0 1 2 0 58555 R Y




Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY



58562 $ 619.85 $ 419.98 0 0% 0% 0% 0 3 0 1 2 0 58555 R Y



58570 $ 1,400.99 $ 1,400.99 90 12% 74% 14% 0 2 0 2 2 0 R Y

58571 $ 1,607.82 $ 1,607.82 90 12% 74% 14% 0 2 0 2 2 0 R Y

58572 $ 1,831.72 $ 1,831.72 90 12% 74% 14% 0 2 0 2 2 0 R Y

58573 $ 2,178.33 $ 2,178.33 90 12% 74% 14% 0 2 0 2 2 0 R Y







58660 $ 1,208.71 $ 1,208.71 90 9% 84% 7% 0 3 0 2 2 0 49320 R Y















58770 $ 1,553.42 $ 1,553.42 90 12% 74% 14% 0 2 1 2 0 0 R Y






58900 $ 745.09 $ 745.09 90 12% 74% 14% 0 2 2 2 1 0 R Y












Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY










59000 $ 228.97 $ 145.48 0 0% 0% 0% 0 2 0 1 0 0 R Y

59001 $ 321.31 $ 321.31 0 0% 0% 0% 0 2 0 1 0 0 R Y

59012 $ 362.42 $ 362.42 0 0% 0% 0% 0 2 0 0 0 0 R Y

59015 $ 280.20 $ 237.19 0 0% 0% 0% 0 2 0 0 0 0 R Y

59020 $ 129.66 $ 129.66 0 0% 0% 0% 1 0 0 0 0 0 R Y

59020-26 $ 65.78 $ 65.78 0 0% 0% 0% 1 0 0 0 0 0 R Y

59020-TC $ 63.88 $ 63.88 0 0% 0% 0% 1 0 0 0 0 0 R Y

59025 $ 87.29 $ 87.29 0 0% 0% 0% 1 0 0 0 0 0 R Y

59025-26 $ 53.13 $ 53.13 0 0% 0% 0% 1 0 0 0 0 0 R Y

59025-TC $ 34.16 $ 34.16 0 0% 0% 0% 1 0 0 0 0 0 R Y


59050 $ 86.65 $ 86.65 0 0% 0% 0% 0 0 0 0 0 0 R Y

59051 $ 75.27 $ 75.27 0 0% 0% 0% 0 0 0 0 0 0 R Y

59070 $ 727.38 $ 550.28 0 0% 0% 0% 0 2 0 2 0 0 R Y

59072 $ 859.57 $ 859.57 0 0% 0% 0% 0 2 0 1 0 0 R Y

59074 $ 702.71 $ 545.85 0 0% 0% 0% 0 2 0 2 0 0 R Y

59076 $ 859.57 $ 859.57 0 0% 0% 0% 0 2 0 2 0 0 R Y


59120 $ 1,415.54 $ 1,415.54 90 17% 60% 23% 0 2 0 2 1 0 R Y

59121 $ 1,421.23 $ 1,421.23 90 17% 60% 23% 0 2 0 2 1 0 R Y

59130 $ 1,660.95 $ 1,660.95 90 17% 60% 23% 0 2 0 0 0 0 R Y

59135 $ 1,525.59 $ 1,525.59 90 17% 60% 23% 0 2 0 0 0 0 R Y

59136 $ 1,572.40 $ 1,572.40 90 17% 60% 23% 0 2 0 2 0 0 R Y

59140 $ 685.63 $ 685.63 90 17% 60% 23% 0 2 0 2 0 0 R Y

59150 $ 1,375.06 $ 1,375.06 90 17% 60% 23% 0 2 0 2 0 0 R Y

59151 $ 1,336.47 $ 1,336.47 90 17% 60% 23% 0 2 0 2 0 0 R Y

59160 $ 366.22 $ 310.56 10 10% 80% 10% 0 2 0 0 0 0 R Y

59200 $ 130.93 $ 80.33 0 0% 0% 0% 0 2 0 1 0 0 R Y

59300 $ 348.51 $ 265.02 0 0% 0% 0% 0 2 0 0 0 0 R Y

59320 $ 273.87 $ 273.87 0 0% 0% 0% 0 2 0 0 0 0 R Y

59325 $ 433.90 $ 433.90 0 0% 0% 0% 0 2 0 0 0 0 R Y

59350 $ 495.88 $ 495.88 0 0% 0% 0% 0 2 0 2 0 0 R Y

59400 $ 3,750.73 $ 3,750.73 45 0% 0% 0% 0 2 0 1 0 0 R Y

59409 $ 1,453.49 $ 1,453.49 0 0% 0% 0% 0 2 0 0 0 0 R Y

59410 $ 1,856.39 $ 1,856.39 45 0% 0% 0% 0 2 0 1 0 0 R Y

59412 $ 184.69 $ 184.69 0 0% 0% 0% 0 0 0 0 0 0 R Y

59414 $ 163.82 $ 163.82 45 0% 0% 0% 0 2 0 0 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


59425 $ 820.35 $ 635.66 0 0% 0% 0% 0 0 0 0 0 0 R Y

59426 $ 1,471.20 $ 1,123.32 0 0% 0% 0% 0 0 0 0 0 0 R Y

59430 $ 333.96 $ 248.57 0 0% 0% 0% 0 2 0 1 0 0 R Y

59510 $ 4,152.36 $ 4,152.36 45 0% 0% 0% 0 2 0 1 0 0 R Y

59514 $ 1,635.01 $ 1,635.01 0 0% 0% 0% 0 2 0 2 1 0 R Y

59515 $ 2,254.23 $ 2,254.23 45 0% 0% 0% 0 2 0 1 0 0 R Y

59525 $ 865.89 $ 865.89 0 0% 0% 0% 0 0 0 2 1 0 R Y

59610 $ 3,934.78 $ 3,934.78 45 0% 0% 0% 0 2 0 0 0 0 R Y

59612 $ 1,633.75 $ 1,633.75 45 0% 0% 0% 0 2 0 0 0 0 R Y

59614 $ 2,034.12 $ 2,034.12 45 0% 0% 0% 0 2 0 0 0 0 R Y

59618 $ 4,205.49 $ 4,205.49 45 0% 0% 0% 0 2 0 0 0 0 R Y

59620 $ 1,673.60 $ 1,673.60 45 0% 0% 0% 0 2 0 2 0 0 R Y

59622 $ 2,299.77 $ 2,299.77 45 0% 0% 0% 0 2 0 0 0 0 R Y

59812 $ 573.05 $ 530.67 90 17% 60% 23% 0 2 0 1 0 0 R Y

59820 $ 685.63 $ 643.25 90 17% 60% 23% 0 2 0 1 0 0 R Y

59821 $ 690.06 $ 643.25 90 17% 60% 23% 0 2 0 0 0 0 R Y

59830 $ 783.67 $ 783.67 90 17% 60% 23% 0 2 0 0 0 0 R Y

59840 $ 390.25 $ 373.81 10 10% 80% 10% 0 2 0 0 0 0 R Y

59841 $ 686.90 $ 646.42 10 10% 80% 10% 0 2 0 0 0 0 R Y

59850 $ 681.20 $ 681.20 90 17% 60% 23% 0 2 0 0 0 0 R Y

59851 $ 716.62 $ 716.62 90 17% 60% 23% 0 2 0 0 0 0 R Y

59852 $ 927.88 $ 927.88 90 17% 60% 23% 0 2 0 0 0 0 R Y

59855 $ 744.45 $ 744.45 90 17% 60% 23% 0 2 0 0 0 0 R Y

59856 $ 873.48 $ 873.48 90 17% 60% 23% 0 2 0 0 0 0 R Y

59857 $ 949.38 $ 949.38 90 17% 60% 23% 0 2 0 0 0 0 R Y



59871 $ 240.98 $ 240.98 0 0% 0% 0% 0 2 0 0 0 0 R Y





60100 $ 206.83 $ 144.21 0 0% 0% 0% 0 2 0 1 0 0 R Y

60200 $ 1,194.79 $ 1,194.79 90 9% 82% 9% 0 2 0 2 1 0 R Y














Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY



60300 $ 218.85 $ 90.45 0 0% 0% 0% 0 2 0 1 0 0 R





60520 $ 1,870.94 $ 1,870.94 90 9% 82% 9% 0 2 0 2 1 0 R Y

60521 $ 2,009.45 $ 2,009.45 90 9% 82% 9% 0 2 0 2 1 0 R Y

60522 $ 2,438.92 $ 2,438.92 90 9% 82% 9% 0 2 0 2 1 0 R Y

60540 $ 1,920.90 $ 1,920.90 90 9% 82% 9% 0 2 1 2 1 0 R Y

60545 $ 2,194.14 $ 2,194.14 90 9% 82% 9% 0 2 1 2 1 0 R Y



60650 $ 2,147.97 $ 2,147.97 90 9% 84% 7% 0 2 1 2 1 0 R Y





61020 $ 182.16 $ 182.16 0 0% 0% 0% 0 2 0 1 0 0 R

61026 $ 190.38 $ 190.38 0 0% 0% 0% 0 2 0 1 0 0 R

61050 $ 157.49 $ 157.49 0 0% 0% 0% 0 2 0 0 0 0 R

61055 $ 220.11 $ 220.11 0 0% 0% 0% 0 0 0 1 0 0 R

61070 $ 104.36 $ 104.36 0 0% 0% 0% 0 2 0 1 0 0 R

61105 $ 800.11 $ 800.11 90 11% 76% 13% 0 2 0 0 0 0 R

61107 $ 559.13 $ 559.13 0 0% 0% 0% 0 0 0 1 0 0 R

61108 $ 1,628.06 $ 1,628.06 90 11% 76% 13% 0 2 0 1 0 0 R

61120 $ 1,340.90 $ 1,340.90 90 11% 76% 13% 0 2 0 0 0 0 R

61140 $ 2,259.29 $ 2,259.29 90 11% 76% 13% 0 2 0 2 0 0 R

61150 $ 2,421.21 $ 2,421.21 90 11% 76% 13% 0 2 0 1 1 0 R

61151 $ 1,785.55 $ 1,785.55 90 11% 76% 13% 0 2 0 1 0 0 R

61154 $ 2,277.00 $ 2,277.00 90 11% 76% 13% 0 2 1 2 1 0 R

61156 $ 2,227.67 $ 2,227.67 90 11% 76% 13% 0 2 0 2 1 0 R

61210 $ 656.54 $ 656.54 0 0% 0% 0% 0 2 0 1 0 0 R

61215 $ 919.02 $ 919.02 90 11% 76% 13% 0 2 0 1 1 0 R

61250 $ 1,496.50 $ 1,496.50 90 11% 76% 13% 0 2 1 2 1 0 R

61253 $ 1,480.68 $ 1,480.68 90 11% 76% 13% 0 2 2 2 0 0 R

61304 $ 2,924.05 $ 2,924.05 90 11% 76% 13% 0 2 0 2 1 0 R

61305 $ 3,598.93 $ 3,598.93 90 11% 76% 13% 0 2 0 2 1 0 R

61312 $ 3,710.25 $ 3,710.25 90 11% 76% 13% 0 2 0 2 1 0 R

61313 $ 3,543.27 $ 3,543.27 90 11% 76% 13% 0 2 0 2 1 0 R

61314 $ 3,266.23 $ 3,266.23 90 11% 76% 13% 0 2 0 2 1 0 R

61315 $ 3,695.07 $ 3,695.07 90 11% 76% 13% 0 2 0 2 1 0 R

61316 $ 157.49 $ 157.49 0 0% 0% 0% 0 0 0 1 0 0 R

61320 $ 3,394.00 $ 3,394.00 90 11% 76% 13% 0 2 0 2 1 0 R

61321 $ 3,774.76 $ 3,774.76 90 11% 76% 13% 0 2 0 2 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


61322 $ 4,244.71 $ 4,244.71 90 11% 76% 13% 0 2 0 2 1 0 R

61323 $ 4,286.45 $ 4,286.45 90 11% 76% 13% 0 2 0 1 1 0 R

61330 $ 3,149.85 $ 3,149.85 90 11% 76% 13% 0 2 1 2 1 0 R

61332 $ 3,141.63 $ 3,141.63 90 11% 76% 13% 0 2 1 2 1 0 R

61333 $ 3,345.29 $ 3,345.29 90 11% 76% 13% 0 2 1 2 1 0 R

61340 $ 2,593.25 $ 2,593.25 90 11% 76% 13% 0 2 1 2 1 0 R

61343 $ 3,918.34 $ 3,918.34 90 11% 76% 13% 0 2 0 2 1 0 R

61345 $ 3,629.92 $ 3,629.92 90 11% 76% 13% 0 2 0 2 1 0 R

61450 $ 3,441.43 $ 3,441.43 90 11% 76% 13% 0 2 0 2 1 0 R

61458 $ 3,587.54 $ 3,587.54 90 11% 76% 13% 0 2 0 2 1 0 R

61460 $ 3,681.15 $ 3,681.15 90 11% 76% 13% 0 2 0 2 2 0 R

61480 $ 3,471.16 $ 3,471.16 90 11% 76% 13% 0 2 0 2 1 0 R

61500 $ 2,370.61 $ 2,370.61 90 11% 76% 13% 0 2 0 2 1 0 R Y

61501 $ 2,066.38 $ 2,066.38 90 11% 76% 13% 0 2 0 2 1 0 R



61514 $ 3,397.79 $ 3,397.79 90 11% 76% 13% 0 2 0 2 1 0 R

61516 $ 3,320.63 $ 3,320.63 90 11% 76% 13% 0 2 0 2 1 0 R Y






61522 $ 3,913.28 $ 3,913.28 90 11% 76% 13% 0 2 0 2 1 0 R Y

61524 $ 3,715.31 $ 3,715.31 90 11% 76% 13% 0 2 0 2 1 0 R Y



61531 $ 2,153.66 $ 2,153.66 90 11% 76% 13% 0 2 0 2 2 0 R

61533 $ 2,707.10 $ 2,707.10 90 11% 76% 13% 0 2 0 2 1 0 R

61534 $ 2,949.35 $ 2,949.35 90 11% 76% 13% 0 2 0 2 1 0 R

61535 $ 1,765.94 $ 1,765.94 90 11% 76% 13% 0 2 0 2 1 0 R

61536 $ 4,571.08 $ 4,571.08 90 11% 76% 13% 0 2 0 2 1 0 R

61537 $ 4,409.16 $ 4,409.16 90 11% 76% 13% 0 2 0 2 1 0 R Y

61538 $ 4,751.34 $ 4,751.34 90 11% 76% 13% 0 2 0 2 1 0 R Y

61539 $ 4,222.57 $ 4,222.57 90 11% 76% 13% 0 2 0 2 1 0 R Y

61540 $ 3,858.25 $ 3,858.25 90 11% 76% 13% 0 2 0 2 1 0 R Y

61541 $ 3,845.60 $ 3,845.60 90 11% 76% 13% 0 2 0 2 1 0 R Y

61543 $ 3,763.38 $ 3,763.38 90 11% 76% 13% 0 2 0 2 1 0 R Y

61544 $ 3,404.75 $ 3,404.75 90 11% 76% 13% 0 2 0 2 0 0 R Y









Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY







61566 $ 4,022.07 $ 4,022.07 90 11% 76% 13% 0 2 0 2 1 0 R Y

61567 $ 4,175.13 $ 4,175.13 90 11% 76% 13% 0 2 0 2 1 0 R Y

61570 $ 3,290.90 $ 3,290.90 90 11% 76% 13% 0 2 0 2 1 0 R

61571 $ 3,560.34 $ 3,560.34 90 11% 76% 13% 0 2 0 2 1 0 R

61575 $ 4,437.62 $ 4,437.62 90 11% 76% 13% 0 2 0 2 1 0 R Y

61576 $ 6,210.52 $ 6,210.52 90 11% 76% 13% 0 2 0 2 1 0 R Y

61580 $ 4,484.43 $ 4,484.43 90 11% 76% 13% 0 2 1 1 1 2 R Y

61581 $ 4,846.22 $ 4,846.22 90 11% 76% 13% 0 2 1 1 2 2 R Y

61582 $ 5,420.53 $ 5,420.53 90 11% 76% 13% 0 2 0 2 1 2 R Y

61583 $ 5,180.81 $ 5,180.81 90 11% 76% 13% 0 2 0 2 1 2 R Y

61584 $ 5,089.73 $ 5,089.73 90 11% 76% 13% 0 2 1 2 1 2 R Y

61585 $ 5,665.94 $ 5,665.94 90 11% 76% 13% 0 2 1 2 1 2 R Y

61586 $ 4,289.62 $ 4,289.62 90 11% 76% 13% 0 2 0 2 1 2 R Y

61590 $ 5,517.30 $ 5,517.30 90 11% 76% 13% 0 2 1 2 1 2 R Y

61591 $ 5,569.80 $ 5,569.80 90 11% 76% 13% 0 2 1 2 1 2 R Y

61592 $ 5,684.91 $ 5,684.91 90 11% 76% 13% 0 2 1 2 1 2 R Y

61595 $ 4,249.77 $ 4,249.77 90 11% 76% 13% 0 2 1 1 1 2 R Y

61596 $ 4,445.84 $ 4,445.84 90 11% 76% 13% 0 2 1 2 1 2 R Y

61597 $ 5,104.91 $ 5,104.91 90 11% 76% 13% 0 2 1 2 1 2 R Y

61598 $ 5,019.52 $ 5,019.52 90 11% 76% 13% 0 2 0 2 1 2 R Y

61600 $ 3,855.72 $ 3,855.72 90 11% 76% 13% 0 2 0 2 1 2 R Y

61601 $ 4,302.90 $ 4,302.90 90 11% 76% 13% 0 2 0 2 1 2 R Y

61605 $ 3,946.17 $ 3,946.17 90 11% 76% 13% 0 2 0 2 1 2 R Y

61606 $ 5,297.19 $ 5,297.19 90 11% 76% 13% 0 2 0 2 1 2 R Y

61607 $ 4,856.97 $ 4,856.97 90 11% 76% 13% 0 2 0 2 1 2 R Y

61608 $ 5,808.25 $ 5,808.25 90 11% 76% 13% 0 2 0 2 1 2 R Y

61610 $ 2,998.05 $ 2,998.05 0 0% 0% 0% 0 0 0 2 1 2 R Y

61611 $ 705.87 $ 705.87 0 0% 0% 0% 0 0 0 2 1 2 R Y

61612 $ 2,180.86 $ 2,180.86 0 0% 0% 0% 0 0 0 2 1 2 R Y

61613 $ 5,779.15 $ 5,779.15 90 11% 76% 13% 0 2 1 2 1 2 R Y

61615 $ 4,457.86 $ 4,457.86 90 11% 76% 13% 0 2 0 2 1 2 R Y

61616 $ 5,961.31 $ 5,961.31 90 11% 76% 13% 0 2 0 2 1 2 R Y

61618 $ 2,320.01 $ 2,320.01 90 11% 76% 13% 0 2 0 2 1 2 R

61619 $ 2,580.60 $ 2,580.60 90 11% 76% 13% 0 2 0 2 1 2 R









Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY




61645 $ 1,403.52 $ 1,403.52 0 0% 0% 0% 0 0 1 0 0 0 R Y

61650 $ 957.61 $ 957.61 0 0% 0% 0% 0 2 0 1 0 0 R Y

61651 $ 407.33 $ 407.33 0 0% 0% 0% 0 2 0 1 0 0 R Y

61680 $ 4,034.72 $ 4,034.72 90 11% 76% 13% 0 2 0 2 1 0 R Y

61682 $ 7,413.53 $ 7,413.53 90 11% 76% 13% 0 2 0 2 1 0 R Y

61684 $ 5,085.93 $ 5,085.93 90 11% 76% 13% 0 2 0 2 1 0 R Y

61686 $ 8,026.43 $ 8,026.43 90 11% 76% 13% 0 2 0 2 1 0 R Y

61690 $ 3,889.88 $ 3,889.88 90 11% 76% 13% 0 2 0 2 1 0 R Y

61692 $ 6,516.65 $ 6,516.65 90 11% 76% 13% 0 2 0 2 1 0 R Y

61697 $ 7,505.25 $ 7,505.25 90 11% 76% 13% 0 2 0 2 1 0 R Y

61698 $ 8,261.08 $ 8,261.08 90 11% 76% 13% 0 2 0 2 1 0 R Y

61700 $ 6,073.27 $ 6,073.27 90 11% 76% 13% 0 2 0 2 1 0 R Y

61702 $ 7,149.78 $ 7,149.78 90 11% 76% 13% 0 2 0 2 1 0 R Y

61703 $ 2,213.75 $ 2,213.75 90 11% 76% 13% 0 2 0 2 1 0 R Y

61705 $ 4,654.57 $ 4,654.57 90 11% 76% 13% 0 2 0 2 1 0 R Y

61708 $ 4,153.00 $ 4,153.00 90 11% 76% 13% 0 2 0 2 0 0 R Y

61710 $ 3,798.80 $ 3,798.80 90 11% 76% 13% 0 2 0 0 0 0 R Y

61711 $ 4,649.51 $ 4,649.51 90 11% 76% 13% 0 2 0 2 1 0 R Y

61720 $ 2,277.00 $ 2,277.00 90 11% 76% 13% 0 2 0 1 0 0 R Y

61735 $ 2,848.78 $ 2,848.78 90 11% 76% 13% 0 2 0 1 1 0 R Y

61750 $ 2,514.19 $ 2,514.19 90 11% 76% 13% 0 2 0 1 1 0 R Y

61751 $ 2,472.44 $ 2,472.44 90 11% 76% 13% 0 2 0 1 1 0 R Y

61760 $ 2,819.69 $ 2,819.69 90 11% 76% 13% 0 2 0 1 2 0 R Y


61781 $ 419.98 $ 419.98 0 0% 0% 0% 0 0 0 0 0 0 R

61782 $ 317.52 $ 317.52 0 0% 0% 0% 0 0 0 0 0 0 R

61783 $ 414.92 $ 414.92 0 0% 0% 0% 0 0 0 0 0 0 R



61796 $ 1,819.70 $ 1,819.70 90 11% 76% 13% 0 0 0 2 0 0 R Y

61797 $ 392.15 $ 392.15 0 0% 0% 0% 0 0 0 2 0 0 R Y

61798 $ 2,470.55 $ 2,470.55 90 11% 76% 13% 0 0 0 2 0 0 R Y

61799 $ 542.69 $ 542.69 0 0% 0% 0% 0 0 0 2 0 0 R Y

61800 $ 276.40 $ 276.40 0 0% 0% 0% 0 0 0 2 0 0 R Y









61885 $ 931.04 $ 931.04 90 11% 76% 13% 0 2 1 0 0 0 R Y-UR



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


61886 $ 1,524.96 $ 1,524.96 90 11% 76% 13% 0 2 0 0 0 0 R Y-UR

61888 $ 710.30 $ 710.30 10 10% 80% 10% 0 2 1 1 0 0 R Y-UR

62000 $ 1,721.67 $ 1,721.67 90 11% 76% 13% 0 2 0 1 0 0 R Y

62005 $ 2,256.13 $ 2,256.13 90 11% 76% 13% 0 2 0 2 1 0 R Y

62010 $ 2,732.40 $ 2,732.40 90 11% 76% 13% 0 2 0 2 1 0 R Y

62100 $ 2,838.03 $ 2,838.03 90 11% 76% 13% 0 2 0 2 1 0 R Y



62120 $ 3,040.43 $ 3,040.43 90 11% 76% 13% 0 2 0 2 1 0 R Y

62121 $ 2,880.41 $ 2,880.41 90 11% 76% 13% 0 2 0 2 1 0 R Y

62140 $ 1,855.12 $ 1,855.12 90 11% 76% 13% 0 2 0 2 1 0 R

62141 $ 2,046.14 $ 2,046.14 90 11% 76% 13% 0 2 0 2 1 0 R

62142 $ 1,593.27 $ 1,593.27 90 11% 76% 13% 0 2 0 2 0 0 R

62143 $ 1,866.51 $ 1,866.51 90 11% 76% 13% 0 2 0 2 1 0 R

62145 $ 2,529.37 $ 2,529.37 90 11% 76% 13% 0 2 0 2 1 0 R

62146 $ 2,151.77 $ 2,151.77 90 11% 76% 13% 0 2 0 2 1 0 R

62147 $ 2,552.14 $ 2,552.14 90 11% 76% 13% 0 2 0 2 1 0 R

62148 $ 225.17 $ 225.17 0 0% 0% 0% 0 0 0 1 0 0 R

62160 $ 339.02 $ 339.02 0 0% 0% 0% 0 0 0 1 0 0 R Y

62161 $ 2,709.63 $ 2,709.63 90 11% 76% 13% 0 2 0 2 1 0 R Y

62162 $ 3,373.12 $ 3,373.12 90 11% 76% 13% 0 2 0 2 1 0 R Y

62163 $ 2,198.57 $ 2,198.57 90 11% 76% 13% 0 2 0 2 1 0 R Y

62164 $ 3,713.41 $ 3,713.41 90 11% 76% 13% 0 2 0 2 1 0 R Y

62165 $ 2,765.29 $ 2,765.29 90 11% 76% 13% 0 2 0 0 1 0 R Y

62180 $ 2,867.12 $ 2,867.12 90 11% 76% 13% 0 2 0 2 0 0 R Y

62190 $ 1,311.17 $ 1,311.17 90 11% 76% 13% 0 2 0 1 1 0 R Y

62192 $ 1,754.56 $ 1,754.56 90 11% 76% 13% 0 2 0 2 1 0 R Y

62194 $ 798.85 $ 798.85 10 10% 80% 10% 0 2 0 0 0 0 R Y

62200 $ 2,419.95 $ 2,419.95 90 11% 76% 13% 0 2 0 2 1 0 R Y

62201 $ 2,156.83 $ 2,156.83 90 11% 76% 13% 0 2 0 1 0 0 R Y

62220 $ 1,849.43 $ 1,849.43 90 11% 76% 13% 0 2 0 2 1 0 R Y

62223 $ 1,875.36 $ 1,875.36 90 11% 76% 13% 0 2 0 2 1 0 R Y

62225 $ 913.96 $ 913.96 90 11% 76% 13% 0 2 0 1 0 0 R Y

62230 $ 1,507.25 $ 1,507.25 90 11% 76% 13% 0 2 0 2 1 0 R Y

62252 $ 154.96 $ 154.96 0 0% 0% 0% 1 0 0 0 0 0 R Y

62252-26 $ 82.86 $ 82.86 0 0% 0% 0% 1 0 0 0 0 0 R Y

62252-TC $ 72.74 $ 72.74 0 0% 0% 0% 1 0 0 0 0 0 R Y

62256 $ 1,079.05 $ 1,079.05 90 11% 76% 13% 0 2 0 2 0 0 R Y

62258 $ 2,001.86 $ 2,001.86 90 11% 76% 13% 0 2 0 2 1 0 R Y


62264 $ 771.65 $ 433.26 10 10% 80% 10% 0 2 0 1 0 0 R Y

62267 $ 457.93 $ 291.58 0 0% 0% 0% 0 2 0 0 0 0 R

62268 $ 473.11 $ 473.11 0 0% 0% 0% 0 2 0 1 0 0 R Y

62269 $ 487.03 $ 487.03 0 0% 0% 0% 0 2 0 0 0 0 R Y

62270 $ 292.22 $ 141.68 0 0% 0% 0% 0 2 0 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


62272 $ 371.91 $ 151.17 0 0% 0% 0% 0 2 0 1 0 0 R Y

62273 $ 316.25 $ 206.83 0 0% 0% 0% 0 2 0 1 0 0 R


62281 $ 442.75 $ 285.26 10 10% 80% 10% 0 2 0 1 0 0 R Y

62282 $ 549.01 $ 267.55 10 10% 80% 10% 0 2 0 1 0 0 R Y

62284 $ 345.98 $ 160.02 0 0% 0% 0% 0 2 0 1 0 0 R Y

62287 $ 1,048.05 $ 1,048.05 90 11% 76% 13% 0 2 0 1 0 0 R Y-UR

62290 $ 609.10 $ 312.46 0 0% 0% 0% 0 2 0 1 0 0 R Y-UR

62291 $ 613.53 $ 311.82 0 0% 0% 0% 0 2 0 1 0 0 R Y-UR

62292 $ 1,061.34 $ 1,061.34 90 11% 76% 13% 0 2 0 0 0 0 R Y-UR

62294 $ 1,698.90 $ 1,698.90 90 11% 76% 13% 0 2 0 1 0 0 R Y

62302 $ 448.44 $ 225.17 0 0% 0% 0% 0 2 0 1 0 0 R Y

62303 $ 462.36 $ 227.07 0 0% 0% 0% 0 2 0 1 0 0 R Y

62304 $ 442.75 $ 220.74 0 0% 0% 0% 0 2 0 1 0 0 R Y

62305 $ 482.60 $ 230.86 0 0% 0% 0% 0 2 0 1 0 0 R Y

62320 $ 306.13 $ 185.96 0 0% 0% 0% 0 2 9 1 0 0 R Y-UR

62321 $ 459.83 $ 200.50 0 0% 0% 0% 0 2 9 1 0 0 R Y-UR

62322 $ 286.52 $ 160.02 0 0% 0% 0% 0 2 9 1 0 0 R Y-UR

62323 $ 452.24 $ 182.79 0 0% 0% 0% 0 2 9 1 0 0 R Y-UR

62324 $ 265.65 $ 167.61 0 0% 0% 0% 0 2 9 1 0 0 R Y-UR

62325 $ 404.80 $ 192.28 0 0% 0% 0% 0 2 9 1 0 0 R Y-UR

62326 $ 280.83 $ 165.08 0 0% 0% 0% 0 2 9 1 0 0 R Y-UR

62327 $ 414.29 $ 175.84 0 0% 0% 0% 0 2 9 1 0 0 R Y-UR

62350 $ 724.85 $ 724.85 10 10% 80% 10% 0 2 0 1 1 0 R Y-UR

62351 $ 1,551.52 $ 1,551.52 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR

62355 $ 487.66 $ 487.66 10 10% 80% 10% 0 2 0 0 0 0 R Y-UR

62360 $ 561.03 $ 561.03 10 10% 80% 10% 0 2 0 0 1 0 R Y-UR

62361 $ 758.37 $ 758.37 10 10% 80% 10% 0 2 0 0 1 0 R Y-UR

62362 $ 697.02 $ 697.02 10 10% 80% 10% 0 2 0 0 1 0 R Y-UR

62365 $ 540.79 $ 540.79 10 10% 80% 10% 0 2 0 0 0 0 R Y-UR

62367 $ 75.27 $ 46.17 0 0% 0% 0% 0 0 0 1 0 0 R Y-UR

62368 $ 103.10 $ 63.88 0 0% 0% 0% 0 0 0 1 0 0 R Y-UR

62369 $ 220.74 $ 64.52 0 0% 0% 0% 0 0 0 1 0 0 R Y

62370 $ 232.13 $ 84.12 0 0% 0% 0% 0 0 0 1 0 0 R Y


63001 $ 2,221.34 $ 2,221.34 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR

63003 $ 2,221.97 $ 2,221.97 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR

63005 $ 2,122.67 $ 2,122.67 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR

63011 $ 1,972.14 $ 1,972.14 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR

63012 $ 2,139.75 $ 2,139.75 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR

63015 $ 2,653.97 $ 2,653.97 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR

63016 $ 2,731.77 $ 2,731.77 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR

63017 $ 2,253.60 $ 2,253.60 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR

63020 $ 2,089.78 $ 2,089.78 90 11% 76% 13% 0 2 1 2 2 0 R Y-UR

63030 $ 1,749.50 $ 1,749.50 90 11% 76% 13% 0 2 1 2 2 0 R Y-UR



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


63035 $ 344.08 $ 344.08 0 0% 0% 0% 0 0 1 2 2 0 R Y-UR

63040 $ 2,504.07 $ 2,504.07 90 11% 76% 13% 0 2 1 2 2 0 R Y-UR

63042 $ 2,335.82 $ 2,335.82 90 11% 76% 13% 0 2 1 2 2 0 R Y-UR

63043 $ 1,174.16 $ 1,174.16 0 0% 0% 0% 0 0 1 2 2 0 F Y-UR

63044 $ 1,098.28 $ 1,098.28 0 0% 0% 0% 0 0 1 2 2 0 F Y-UR

63045 $ 2,312.42 $ 2,312.42 90 11% 76% 13% 0 2 2 2 2 0 R Y-UR

63046 $ 2,199.20 $ 2,199.20 90 11% 76% 13% 0 2 2 2 2 0 R Y-UR

63047 $ 1,986.05 $ 1,986.05 90 11% 76% 13% 0 2 2 2 2 0 R Y-UR

63048 $ 378.87 $ 378.87 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

63050 $ 2,703.94 $ 2,703.94 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR

63051 $ 3,073.95 $ 3,073.95 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR

63055 $ 2,914.56 $ 2,914.56 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63056 $ 2,664.72 $ 2,664.72 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63057 $ 573.68 $ 573.68 0 0% 0% 0% 0 0 0 2 1 0 R Y-UR

63064 $ 3,173.89 $ 3,173.89 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63066 $ 366.85 $ 366.85 0 0% 0% 0% 0 0 0 2 1 0 R Y-UR

63075 $ 2,433.86 $ 2,433.86 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR

63076 $ 443.38 $ 443.38 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

63077 $ 2,680.54 $ 2,680.54 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR

63078 $ 349.77 $ 349.77 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR

63081 $ 3,154.28 $ 3,154.28 90 11% 76% 13% 0 2 0 2 1 2 R Y-UR

63082 $ 476.91 $ 476.91 0 0% 0% 0% 0 0 0 2 1 2 R Y-UR

63085 $ 3,433.84 $ 3,433.84 90 11% 76% 13% 0 2 0 2 2 2 R Y-UR

63086 $ 342.18 $ 342.18 0 0% 0% 0% 0 0 0 2 2 2 R Y-UR

63087 $ 4,324.40 $ 4,324.40 90 11% 76% 13% 0 2 0 2 2 2 R Y-UR

63088 $ 466.15 $ 466.15 0 0% 0% 0% 0 0 0 2 2 2 R Y-UR

63090 $ 3,529.98 $ 3,529.98 90 11% 76% 13% 0 2 0 2 2 2 R Y-UR

63091 $ 320.68 $ 320.68 0 0% 0% 0% 0 0 0 2 2 2 R Y-UR

63101 $ 4,147.30 $ 4,147.30 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63102 $ 4,085.32 $ 4,085.32 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63103 $ 524.98 $ 524.98 0 0% 0% 0% 0 0 0 2 1 0 R Y-UR

63170 $ 2,855.11 $ 2,855.11 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63172 $ 2,519.88 $ 2,519.88 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63173 $ 3,053.08 $ 3,053.08 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63180 $ 2,418.05 $ 2,418.05 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63182 $ 2,924.05 $ 2,924.05 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63185 $ 2,061.32 $ 2,061.32 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63190 $ 2,311.79 $ 2,311.79 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63191 $ 2,295.98 $ 2,295.98 90 11% 76% 13% 0 2 1 2 1 0 R Y-UR

63194 $ 2,527.47 $ 2,527.47 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63195 $ 2,320.01 $ 2,320.01 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63196 $ 2,571.75 $ 2,571.75 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63197 $ 2,583.13 $ 2,583.13 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63198 $ 3,029.04 $ 3,029.04 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63199 $ 3,177.68 $ 3,177.68 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


63200 $ 2,743.79 $ 2,743.79 90 11% 76% 13% 0 2 0 2 0 0 R Y-UR

63250 $ 5,306.68 $ 5,306.68 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63251 $ 5,381.94 $ 5,381.94 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63252 $ 5,401.55 $ 5,401.55 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63265 $ 2,984.14 $ 2,984.14 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63266 $ 3,075.22 $ 3,075.22 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63267 $ 2,457.26 $ 2,457.26 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63268 $ 2,511.03 $ 2,511.03 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63270 $ 3,705.19 $ 3,705.19 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63271 $ 3,681.78 $ 3,681.78 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63272 $ 3,375.02 $ 3,375.02 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63273 $ 3,279.51 $ 3,279.51 90 11% 76% 13% 0 2 0 2 0 0 R Y-UR

63275 $ 3,213.10 $ 3,213.10 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63276 $ 3,196.02 $ 3,196.02 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63277 $ 2,781.74 $ 2,781.74 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63278 $ 2,820.32 $ 2,820.32 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63280 $ 3,765.91 $ 3,765.91 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63281 $ 3,736.18 $ 3,736.18 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63282 $ 3,518.60 $ 3,518.60 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63283 $ 3,373.76 $ 3,373.76 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63285 $ 4,680.50 $ 4,680.50 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63286 $ 4,579.30 $ 4,579.30 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63287 $ 4,910.10 $ 4,910.10 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63290 $ 4,973.35 $ 4,973.35 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63295 $ 590.76 $ 590.76 0 0% 0% 0% 0 0 2 2 2 0 R Y-UR

63300 $ 3,282.68 $ 3,282.68 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63301 $ 3,722.26 $ 3,722.26 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63302 $ 3,838.64 $ 3,838.64 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63303 $ 4,011.32 $ 4,011.32 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63304 $ 4,146.04 $ 4,146.04 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63305 $ 4,291.51 $ 4,291.51 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63306 $ 3,722.90 $ 3,722.90 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63307 $ 3,926.56 $ 3,926.56 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63308 $ 575.58 $ 575.58 0 0% 0% 0% 0 0 0 2 1 0 R Y-UR

63600 $ 1,642.60 $ 1,642.60 90 11% 76% 13% 0 2 0 0 0 0 R Y

63610 $ 825.41 $ 825.41 0 0% 0% 0% 0 2 0 0 0 0 R Y

63615 $ 2,217.55 $ 2,217.55 90 11% 76% 13% 0 2 0 1 1 0 R Y

63620 $ 2,004.39 $ 2,004.39 90 11% 76% 13% 0 0 0 2 0 0 R Y

63621 $ 447.81 $ 447.81 0 0% 0% 0% 0 0 0 2 0 0 R Y

63650 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X Y

63655 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X Y-UR







Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


63685 Not Covered Not Covered 10 10% 80% 10% 0 2 0 2 1 0 X Y-UR

63688 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X Y

63700 $ 2,099.27 $ 2,099.27 90 11% 76% 13% 0 2 0 2 1 0 R Y

63702 $ 2,328.23 $ 2,328.23 90 11% 76% 13% 0 2 0 2 1 0 R Y

63704 $ 2,666.62 $ 2,666.62 90 11% 76% 13% 0 2 0 2 1 0 R Y

63706 $ 3,147.32 $ 3,147.32 90 11% 76% 13% 0 2 0 2 1 0 R Y

63707 $ 1,658.42 $ 1,658.42 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63709 $ 1,981.62 $ 1,981.62 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

63710 $ 1,950.00 $ 1,950.00 90 11% 76% 13% 0 2 0 2 1 0 R Y

63740 $ 1,678.66 $ 1,678.66 90 11% 76% 13% 0 2 0 2 1 0 R Y

63741 $ 1,215.67 $ 1,215.67 90 11% 76% 13% 0 2 0 2 1 0 R Y

63744 $ 1,188.47 $ 1,188.47 90 11% 76% 13% 0 2 0 2 1 0 R Y

63746 $ 1,083.47 $ 1,083.47 90 11% 76% 13% 0 2 0 0 0 0 R Y

64400 $ 233.39 $ 128.40 0 0% 0% 0% 0 2 1 1 0 0 R

64402 $ 243.51 $ 144.21 0 0% 0% 0% 0 2 1 1 0 0 R

64405 $ 183.43 $ 113.85 0 0% 0% 0% 0 2 1 1 0 0 R

64408 $ 216.95 $ 157.49 0 0% 0% 0% 0 2 1 0 0 0 R

64410 $ 248.57 $ 136.62 0 0% 0% 0% 0 2 1 0 0 0 R

64413 $ 232.76 $ 146.74 0 0% 0% 0% 0 2 1 1 0 0 R

64415 $ 214.42 $ 117.01 0 0% 0% 0% 0 2 1 1 0 0 R

64416 $ 142.31 $ 142.31 0 0% 0% 0% 0 2 1 1 0 0 R Y

64417 $ 235.29 $ 127.13 0 0% 0% 0% 0 2 1 1 0 0 R

64418 $ 267.55 $ 139.15 0 0% 0% 0% 0 2 1 1 0 0 R

64420 $ 204.30 $ 123.34 0 0% 0% 0% 0 2 0 1 0 0 R

64421 $ 275.14 $ 166.98 0 0% 0% 0% 0 2 1 1 0 0 R

64425 $ 240.35 $ 169.51 0 0% 0% 0% 0 2 1 1 0 0 R

64430 $ 252.37 $ 148.01 0 0% 0% 0% 0 2 1 1 0 0 R

64435 $ 247.94 $ 150.54 0 0% 0% 0% 0 2 1 1 0 0 R

64445 $ 248.57 $ 130.30 0 0% 0% 0% 0 2 1 1 0 0 R

64446 $ 142.31 $ 142.31 0 0% 0% 0% 0 2 1 1 0 0 R Y

64447 $ 218.21 $ 119.54 0 0% 0% 0% 0 2 1 1 0 0 R Y

64448 $ 128.40 $ 128.40 0 0% 0% 0% 0 2 1 1 0 0 R Y

64449 $ 151.17 $ 151.17 0 0% 0% 0% 0 2 1 1 0 0 R Y

64450 $ 147.37 $ 82.86 0 0% 0% 0% 0 2 1 1 0 0 R

64455 $ 87.29 $ 63.25 0 0% 0% 0% 0 2 1 0 0 0 R

64461 $ 271.98 $ 157.49 0 0% 0% 0% 0 2 1 1 0 0 R Y

64462 $ 153.70 $ 98.67 0 0% 0% 0% 0 0 1 1 0 0 R Y

64463 $ 304.87 $ 161.29 0 0% 0% 0% 0 2 1 1 0 0 R Y

64479 $ 432.00 $ 241.62 0 0% 0% 0% 0 2 1 1 0 0 R Y-UR

64480 $ 206.20 $ 115.12 0 0% 0% 0% 0 0 1 1 0 0 R Y-UR

64483 $ 402.27 $ 204.93 0 0% 0% 0% 0 2 1 1 0 0 R Y-UR

64484 $ 160.66 $ 94.88 0 0% 0% 0% 0 0 1 1 0 0 R Y-UR

64486 $ 223.27 $ 112.59 0 0% 0% 0% 0 2 1 1 0 0 R Y

64487 $ 247.94 $ 122.07 0 0% 0% 0% 0 2 1 1 0 0 R Y

64488 $ 256.16 $ 133.46 0 0% 0% 0% 0 2 2 1 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


64489 $ 328.90 $ 142.31 0 0% 0% 0% 0 2 2 1 0 0 R Y

64490 $ 347.88 $ 194.18 0 0% 0% 0% 0 2 1 2 0 0 R Y-UR

64491 $ 170.78 $ 109.42 0 0% 0% 0% 0 0 1 2 0 0 R Y-UR

64492 $ 171.41 $ 111.32 0 0% 0% 0% 0 0 1 2 0 0 R Y-UR

64493 $ 316.25 $ 165.72 0 0% 0% 0% 0 2 1 2 0 0 R Y-UR

64494 $ 157.49 $ 94.24 0 0% 0% 0% 0 0 1 2 0 0 R Y-UR

64495 $ 158.13 $ 95.51 0 0% 0% 0% 0 0 1 2 0 0 R Y-UR

64505 $ 192.91 $ 160.02 0 0% 0% 0% 0 2 1 1 0 0 R Y

64508 $ 107.53 $ 130.93 0 0% 0% 0% 0 2 1 0 0 0 R Y

64510 $ 233.39 $ 134.09 0 0% 0% 0% 0 2 1 1 0 0 R Y


64520 $ 343.45 $ 148.01 0 0% 0% 0% 0 2 1 1 0 0 R Y

64530 $ 349.14 $ 166.98 0 0% 0% 0% 0 2 0 1 0 0 R Y

64550 $ 29.10 $ 15.81 0 0% 0% 0% 0 0 0 1 0 0 R

64553 $ 373.18 $ 278.30 10 10% 80% 10% 0 2 0 0 0 0 R Y-UR


64561 $ 1,531.28 $ 552.81 10 10% 80% 10% 0 2 1 1 0 0 R Y

64565 $ 356.10 $ 246.04 10 10% 80% 10% 0 2 0 1 0 0 R Y


64568 $ 1,168.23 $ 1,168.23 90 11% 76% 13% 0 2 1 0 0 0 R Y-UR

64569 $ 1,402.25 $ 1,402.25 90 11% 76% 13% 0 2 1 0 1 1 R Y-UR

64570 $ 1,178.35 $ 1,178.35 90 11% 76% 13% 0 2 1 0 1 1 R Y-UR


64580 $ 544.58 $ 544.58 90 11% 76% 13% 0 2 0 2 0 0 R Y

64581 $ 1,208.08 $ 1,208.08 90 11% 76% 13% 0 2 0 1 0 0 R Y

64585 $ 453.50 $ 262.49 10 10% 80% 10% 0 2 0 1 0 0 R Y


64595 $ 456.03 $ 231.50 10 10% 80% 10% 0 2 0 1 0 0 R Y

64600 $ 720.42 $ 397.84 10 10% 80% 10% 0 2 2 1 0 0 R Y

64605 $ 1,117.63 $ 626.18 10 10% 80% 10% 0 2 1 0 0 0 R Y

64610 $ 1,347.23 $ 874.75 10 10% 80% 10% 0 2 1 1 0 0 R Y

64611 $ 212.52 $ 185.96 10 10% 80% 10% 0 2 2 0 0 0 R Y

64612 $ 237.82 $ 212.52 10 10% 80% 10% 0 2 1 1 0 0 R Y

64615 $ 257.43 $ 221.38 10 10% 80% 10% 0 2 2 1 0 0 R Y

64616 $ 227.07 $ 196.08 10 10% 80% 10% 0 2 1 1 0 0 R Y

64617 $ 325.11 $ 211.26 10 10% 80% 10% 0 2 1 1 0 0 R Y

64620 $ 372.54 $ 313.72 10 10% 80% 10% 0 2 0 1 0 0 R Y

64630 $ 419.35 $ 347.88 10 10% 80% 10% 0 2 0 0 0 0 R Y

64632 $ 156.86 $ 125.87 10 10% 80% 10% 0 2 1 0 0 0 R Y

64633 $ 772.92 $ 413.02 10 10% 80% 10% 0 2 1 1 0 0 R Y-UR

64634 $ 348.51 $ 124.60 0 0% 0% 0% 0 0 1 1 0 0 R Y-UR

64635 $ 764.69 $ 407.33 10 10% 80% 10% 0 2 1 1 0 0 R Y-UR

64636 $ 317.52 $ 108.79 0 0% 0% 0% 0 0 1 1 0 0 R Y-UR

64640 $ 244.15 $ 171.41 10 10% 80% 10% 0 2 1 1 0 0 R Y

64642 $ 256.80 $ 196.08 0 0% 0% 0% 0 2 0 1 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


64643 $ 167.61 $ 130.30 0 0% 0% 0% 0 0 0 1 0 0 R Y

64644 $ 296.64 $ 214.42 0 0% 0% 0% 0 2 0 1 0 0 R Y

64645 $ 207.46 $ 149.90 0 0% 0% 0% 0 0 0 1 0 0 R Y

64646 $ 268.81 $ 209.36 0 0% 0% 0% 0 2 0 1 0 0 R Y

64647 $ 319.41 $ 246.68 0 0% 0% 0% 0 2 0 1 0 0 R Y

64650 $ 142.31 $ 76.53 0 0% 0% 0% 0 2 0 0 0 0 R Y

64653 $ 171.41 $ 96.14 0 0% 0% 0% 0 2 0 0 0 0 R Y

64680 $ 565.46 $ 301.70 10 10% 80% 10% 0 2 0 1 0 0 R Y

64681 $ 958.24 $ 485.76 10 10% 80% 10% 0 2 0 1 0 0 R Y

64702 $ 913.33 $ 913.33 90 11% 76% 13% 0 2 0 1 0 0 R Y

64704 $ 585.70 $ 585.70 90 11% 76% 13% 0 2 0 2 1 0 R Y

64708 $ 908.27 $ 908.27 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

64712 $ 1,053.75 $ 1,053.75 90 11% 76% 13% 0 2 1 2 1 0 R Y

64713 $ 1,386.44 $ 1,386.44 90 11% 76% 13% 0 2 1 2 1 0 R Y-UR

64714 $ 1,287.77 $ 1,287.77 90 11% 76% 13% 0 2 1 2 1 0 R Y

64716 $ 974.68 $ 974.68 90 11% 76% 13% 0 2 0 2 1 0 R Y

64718 $ 1,077.78 $ 1,077.78 90 11% 76% 13% 0 2 1 0 0 0 R Y-UR

64719 $ 729.27 $ 729.27 90 11% 76% 13% 0 2 1 1 0 0 R Y-UR

64721 $ 783.04 $ 777.98 90 11% 76% 13% 0 2 1 1 0 0 R Y-UR

64722 $ 661.60 $ 661.60 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR

64726 $ 500.94 $ 500.94 90 11% 76% 13% 0 2 0 1 0 0 R Y

64727 $ 332.70 $ 332.70 0 0% 0% 0% 0 0 0 1 0 0 R Y-UR

64732 $ 686.90 $ 686.90 90 11% 76% 13% 0 2 1 2 0 0 R Y

64734 $ 902.58 $ 902.58 90 11% 76% 13% 0 2 1 0 0 0 R Y

64736 $ 710.30 $ 710.30 90 11% 76% 13% 0 2 1 2 0 0 R Y

64738 $ 839.33 $ 839.33 90 11% 76% 13% 0 2 1 2 0 0 R Y

64740 $ 827.94 $ 827.94 90 11% 76% 13% 0 2 1 2 0 0 R Y

64742 $ 828.58 $ 828.58 90 11% 76% 13% 0 2 1 2 0 0 R Y

64744 $ 879.18 $ 879.18 90 11% 76% 13% 0 2 1 0 0 0 R Y

64746 $ 765.33 $ 765.33 90 11% 76% 13% 0 2 1 2 1 0 R Y

64755 $ 1,560.38 $ 1,560.38 90 11% 76% 13% 0 2 0 2 1 0 R Y

64760 $ 894.36 $ 894.36 90 11% 76% 13% 0 2 0 2 1 0 R Y

64763 $ 867.79 $ 867.79 90 11% 76% 13% 0 2 1 2 1 0 R Y

64766 $ 1,030.98 $ 1,030.98 90 11% 76% 13% 0 2 1 2 0 0 R Y

64771 $ 1,094.23 $ 1,094.23 90 11% 76% 13% 0 2 0 2 0 0 R Y

64772 $ 1,022.75 $ 1,022.75 90 11% 76% 13% 0 2 0 2 1 0 R Y

64774 $ 753.31 $ 753.31 90 11% 76% 13% 0 2 0 1 0 0 R

64776 $ 709.03 $ 709.03 90 11% 76% 13% 0 2 0 0 0 0 R

64778 $ 258.69 $ 258.69 0 0% 0% 0% 0 0 0 1 0 0 R

64782 $ 830.47 $ 830.47 90 11% 76% 13% 0 2 0 1 1 0 R

64783 $ 402.90 $ 402.90 0 0% 0% 0% 0 0 0 1 0 0 R

64784 $ 1,325.09 $ 1,325.09 90 11% 76% 13% 0 2 0 0 0 0 R

64786 $ 1,959.49 $ 1,959.49 90 11% 76% 13% 0 2 1 2 0 0 R

64787 $ 440.85 $ 440.85 0 0% 0% 0% 0 0 0 0 0 0 R

64788 $ 725.48 $ 725.48 90 11% 76% 13% 0 2 0 1 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


64790 $ 1,523.06 $ 1,523.06 90 11% 76% 13% 0 2 0 0 1 0 R Y

64792 $ 1,974.03 $ 1,974.03 90 11% 76% 13% 0 2 0 2 1 0 R Y

64795 $ 347.24 $ 347.24 0 0% 0% 0% 0 2 0 1 0 0 R Y

64802 $ 1,169.49 $ 1,169.49 90 11% 76% 13% 0 2 1 2 1 0 R Y

64804 $ 1,606.55 $ 1,606.55 90 11% 76% 13% 0 2 1 2 1 0 R Y

64809 $ 1,617.94 $ 1,617.94 90 11% 76% 13% 0 2 1 2 1 0 R Y

64818 $ 1,040.46 $ 1,040.46 90 11% 76% 13% 0 2 1 2 1 0 R Y

64820 $ 1,291.57 $ 1,291.57 90 11% 76% 13% 0 2 0 1 0 0 R Y

64821 $ 1,261.84 $ 1,261.84 90 11% 76% 13% 0 2 1 1 0 0 R Y

64822 $ 1,261.21 $ 1,261.21 90 11% 76% 13% 0 2 1 1 0 0 R Y

64823 $ 1,430.08 $ 1,430.08 90 11% 76% 13% 0 2 1 1 0 0 R Y

64831 $ 1,251.72 $ 1,251.72 90 11% 76% 13% 0 2 1 1 0 0 R

64832 $ 612.89 $ 612.89 0 0% 0% 0% 0 0 0 0 0 0 R

64834 $ 1,355.45 $ 1,355.45 90 11% 76% 13% 0 2 1 0 0 0 R

64835 $ 1,462.97 $ 1,462.97 90 11% 76% 13% 0 2 1 2 0 0 R

64836 $ 1,500.92 $ 1,500.92 90 11% 76% 13% 0 2 1 2 0 0 R

64837 $ 693.85 $ 693.85 0 0% 0% 0% 0 0 0 2 0 0 R

64840 $ 1,761.51 $ 1,761.51 90 11% 76% 13% 0 2 1 2 0 0 R

64856 $ 1,836.78 $ 1,836.78 90 11% 76% 13% 0 2 0 1 1 0 R

64857 $ 1,916.48 $ 1,916.48 90 11% 76% 13% 0 2 0 2 1 0 R

64858 $ 2,123.30 $ 2,123.30 90 11% 76% 13% 0 2 1 2 1 0 R

64859 $ 457.30 $ 457.30 0 0% 0% 0% 0 0 0 2 1 0 R

64861 $ 2,264.98 $ 2,264.98 90 11% 76% 13% 0 2 1 2 1 0 R

64862 $ 2,493.32 $ 2,493.32 90 11% 76% 13% 0 2 1 2 0 0 R

64864 $ 1,604.02 $ 1,604.02 90 11% 76% 13% 0 2 0 2 1 0 R

64865 $ 2,041.08 $ 2,041.08 90 11% 76% 13% 0 2 0 2 1 0 R

64866 $ 2,092.31 $ 2,092.31 90 11% 76% 13% 0 2 0 2 1 0 R

64868 $ 1,881.69 $ 1,881.69 90 11% 76% 13% 0 2 0 2 1 0 R

64872 $ 211.26 $ 211.26 0 0% 0% 0% 0 0 0 2 1 0 R

64874 $ 298.54 $ 298.54 0 0% 0% 0% 0 0 0 2 1 0 R

64876 $ 321.31 $ 321.31 0 0% 0% 0% 0 0 0 2 1 0 R

64885 $ 2,068.28 $ 2,068.28 90 11% 76% 13% 0 2 0 2 1 0 R

64886 $ 2,367.45 $ 2,367.45 90 11% 76% 13% 0 2 0 2 1 0 R

64890 $ 1,988.58 $ 1,988.58 90 11% 76% 13% 0 2 0 2 0 0 R

64891 $ 2,105.59 $ 2,105.59 90 11% 76% 13% 0 2 0 2 0 0 R

64892 $ 1,891.18 $ 1,891.18 90 11% 76% 13% 0 2 0 2 1 0 R

64893 $ 2,075.87 $ 2,075.87 90 11% 76% 13% 0 2 0 2 0 0 R

64895 $ 2,435.13 $ 2,435.13 90 11% 76% 13% 0 2 0 2 1 0 R

64896 $ 2,616.65 $ 2,616.65 90 11% 76% 13% 0 2 0 2 1 0 R

64897 $ 2,335.82 $ 2,335.82 90 11% 76% 13% 0 2 0 2 0 0 R

64898 $ 2,641.32 $ 2,641.32 90 11% 76% 13% 0 2 0 2 1 0 R

64901 $ 1,011.37 $ 1,011.37 0 0% 0% 0% 0 0 0 2 1 0 R

64902 $ 1,180.25 $ 1,180.25 0 0% 0% 0% 0 0 0 2 0 0 R

64905 $ 1,881.06 $ 1,881.06 90 11% 76% 13% 0 2 0 2 1 0 R

64907 $ 2,420.58 $ 2,420.58 90 11% 76% 13% 0 2 0 2 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


64910 $ 1,498.39 $ 1,498.39 90 11% 76% 13% 0 2 0 2 1 0 R

64911 $ 1,856.39 $ 1,856.39 90 11% 76% 13% 0 2 0 2 1 0 R


65091 $ 1,166.33 $ 1,166.33 90 10% 70% 20% 0 2 1 0 1 0 R

65093 $ 1,153.05 $ 1,153.05 90 10% 70% 20% 0 2 1 1 1 0 R

65101 $ 1,354.82 $ 1,354.82 90 10% 70% 20% 0 2 1 1 0 0 R

65103 $ 1,413.01 $ 1,413.01 90 10% 70% 20% 0 2 1 1 1 0 R

65105 $ 1,555.95 $ 1,555.95 90 10% 70% 20% 0 2 1 2 1 0 R

65110 $ 2,238.42 $ 2,238.42 90 10% 70% 20% 0 2 1 2 1 0 R

65112 $ 2,596.41 $ 2,596.41 90 10% 70% 20% 0 2 1 2 1 0 R

65114 $ 2,704.57 $ 2,704.57 90 10% 70% 20% 0 2 1 2 1 0 R

65125 $ 834.90 $ 529.40 90 10% 70% 20% 0 2 1 1 1 0 R

65130 $ 1,340.90 $ 1,340.90 90 10% 70% 20% 0 2 1 1 1 0 R

65135 $ 1,361.14 $ 1,361.14 90 10% 70% 20% 0 2 1 1 0 0 R

65140 $ 1,478.79 $ 1,478.79 90 10% 70% 20% 0 2 1 1 0 0 R

65150 $ 1,061.34 $ 1,061.34 90 10% 70% 20% 0 2 1 0 0 0 R

65155 $ 1,547.73 $ 1,547.73 90 10% 70% 20% 0 2 1 1 0 0 R

65175 $ 1,206.81 $ 1,206.81 90 10% 70% 20% 0 2 1 1 1 0 R

65205 $ 103.10 $ 80.33 0 0% 0% 0% 0 2 1 1 0 0 R

65210 $ 125.87 $ 97.41 0 0% 0% 0% 0 2 1 1 0 0 R

65220 $ 106.26 $ 76.53 0 0% 0% 0% 0 2 1 1 0 0 R

65222 $ 122.71 $ 94.88 0 0% 0% 0% 0 2 1 1 0 0 R

65235 $ 1,299.16 $ 1,299.16 90 10% 70% 20% 0 2 1 0 0 0 R

65260 $ 1,757.72 $ 1,757.72 90 10% 70% 20% 0 2 1 2 0 0 R

65265 $ 1,977.83 $ 1,977.83 90 10% 70% 20% 0 2 1 2 1 0 R

65270 $ 491.45 $ 256.80 10 10% 80% 10% 0 2 1 0 0 0 R

65272 $ 925.35 $ 641.99 90 10% 70% 20% 0 2 1 1 0 0 R

65273 $ 696.38 $ 696.38 90 10% 70% 20% 0 2 1 1 1 0 R

65275 $ 1,060.70 $ 844.39 90 10% 70% 20% 0 2 1 0 0 0 R

65280 $ 1,227.68 $ 1,227.68 90 10% 70% 20% 0 2 1 0 0 0 R

65285 $ 2,025.27 $ 2,025.27 90 10% 70% 20% 0 2 1 1 0 0 R

65286 $ 1,296.63 $ 906.37 90 10% 70% 20% 0 2 1 1 0 0 R

65290 $ 899.42 $ 899.42 90 10% 70% 20% 0 2 1 1 1 0 R

65400 $ 1,247.92 $ 1,105.61 90 10% 70% 20% 0 2 1 1 0 0 R

65410 $ 262.49 $ 191.02 0 0% 0% 0% 0 2 1 0 0 0 R

65420 $ 952.55 $ 693.22 90 10% 70% 20% 0 2 1 1 0 0 R

65426 $ 1,201.12 $ 877.28 90 10% 70% 20% 0 2 1 1 0 0 R

65430 $ 208.73 $ 189.75 0 0% 0% 0% 0 2 1 1 0 0 R

65435 $ 146.74 $ 127.77 0 0% 0% 0% 0 2 1 1 0 0 R

65436 $ 709.67 $ 680.57 90 10% 70% 20% 0 2 1 1 0 0 R

65450 $ 597.71 $ 591.39 90 10% 70% 20% 0 2 1 1 0 0 R

65600 $ 724.85 $ 631.87 90 10% 70% 20% 0 2 1 1 0 0 R

65710 $ 2,022.74 $ 2,022.74 90 10% 70% 20% 0 2 1 2 1 0 R

65730 $ 2,244.11 $ 2,244.11 90 10% 70% 20% 0 2 1 2 1 0 R

65750 $ 2,254.23 $ 2,254.23 90 10% 70% 20% 0 2 1 2 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


65755 $ 2,242.85 $ 2,242.85 90 10% 70% 20% 0 2 1 2 1 0 R

65756 $ 2,162.52 $ 2,162.52 90 10% 70% 20% 0 2 1 2 1 0 R


65760 $ 3,897.45 $ 3,897.45 0 0% 0% 0% 9 9 9 9 9 9 F

65765 $ 4,261.52 $ 4,261.52 0 0% 0% 0% 9 9 9 9 9 9 F


65770 $ 2,559.73 $ 2,559.73 90 10% 70% 20% 0 2 1 2 0 0 R


65772 $ 827.94 $ 745.09 90 10% 70% 20% 0 2 1 1 0 0 R

65775 $ 1,010.10 $ 1,010.10 90 10% 70% 20% 0 2 1 1 0 0 R

65778 $ 2,671.05 $ 104.36 10 10% 80% 10% 0 2 1 0 0 0 R

65779 $ 2,252.97 $ 276.40 10 10% 80% 10% 0 2 1 0 0 0 R

65780 $ 1,223.89 $ 1,223.89 90 10% 70% 20% 0 2 1 1 1 0 R

65781 $ 2,437.66 $ 2,437.66 90 10% 70% 20% 0 2 1 2 1 0 R

65782 $ 2,104.33 $ 2,104.33 90 10% 70% 20% 0 2 1 1 1 0 R

65785 $ 3,953.76 $ 702.71 90 10% 70% 20% 0 2 1 1 1 0 R Y

65800 $ 217.58 $ 166.35 0 0% 0% 0% 0 2 1 1 0 0 R Y

65810 $ 852.61 $ 852.61 90 10% 70% 20% 0 2 1 1 0 0 R

65815 $ 1,173.92 $ 875.38 90 10% 70% 20% 0 2 1 1 0 0 R

65820 $ 1,371.89 $ 1,371.89 90 10% 70% 20% 0 2 1 0 0 0 R

65850 $ 1,534.45 $ 1,534.45 90 10% 70% 20% 0 2 1 1 1 0 R

65855 $ 447.81 $ 379.50 10 10% 80% 10% 0 2 1 1 0 0 R

65860 $ 565.46 $ 462.99 90 10% 70% 20% 0 2 1 0 0 0 R

65865 $ 867.16 $ 867.16 90 10% 70% 20% 0 2 1 1 1 0 R

65870 $ 1,082.84 $ 1,082.84 90 10% 70% 20% 0 2 1 1 1 0 R

65875 $ 1,154.95 $ 1,154.95 90 10% 70% 20% 0 2 1 1 1 0 R

65880 $ 1,215.03 $ 1,215.03 90 10% 70% 20% 0 2 1 1 0 0 R

65900 $ 1,763.41 $ 1,763.41 90 10% 70% 20% 0 2 1 2 0 0 R

65920 $ 1,443.37 $ 1,443.37 90 10% 70% 20% 0 2 1 1 1 0 R

65930 $ 1,165.70 $ 1,165.70 90 10% 70% 20% 0 2 1 1 1 0 R

66020 $ 344.08 $ 240.35 10 10% 80% 10% 0 2 1 1 0 0 R

66030 $ 306.76 $ 203.67 10 10% 80% 10% 0 2 1 1 0 0 R

66130 $ 1,277.65 $ 1,041.10 90 10% 70% 20% 0 2 1 0 0 0 R

66150 $ 1,607.18 $ 1,607.18 90 10% 70% 20% 0 2 1 1 1 0 R

66155 $ 1,605.92 $ 1,605.92 90 10% 70% 20% 0 2 1 1 0 0 R

66160 $ 1,808.95 $ 1,808.95 90 10% 70% 20% 0 2 1 1 1 0 R

66170 $ 2,003.76 $ 2,003.76 90 10% 70% 20% 0 2 1 2 1 0 R

66172 $ 2,182.13 $ 2,182.13 90 10% 70% 20% 0 2 1 2 1 0 R

66174 $ 1,733.05 $ 1,733.05 90 10% 70% 20% 0 2 1 2 1 0 R Y

66175 $ 1,814.01 $ 1,814.01 90 10% 70% 20% 0 2 1 2 1 0 R Y

66179 $ 1,972.14 $ 1,972.14 90 10% 70% 20% 0 2 1 2 0 0 R

66180 $ 2,080.29 $ 2,080.29 90 10% 70% 20% 0 2 1 2 0 0 R


66184 $ 1,438.94 $ 1,438.94 90 10% 70% 20% 0 2 1 2 0 0 R

66185 $ 1,546.46 $ 1,546.46 90 10% 70% 20% 0 2 1 2 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


66220 $ 1,295.99 $ 1,295.99 90 10% 70% 20% 0 2 1 2 1 0 R

66225 $ 1,703.96 $ 1,703.96 90 10% 70% 20% 0 2 1 1 1 0 R

66250 $ 1,378.85 $ 1,020.86 90 10% 70% 20% 0 2 1 1 0 0 R

66500 $ 651.48 $ 651.48 90 10% 70% 20% 0 2 1 1 1 0 R

66505 $ 716.62 $ 716.62 90 10% 70% 20% 0 2 1 1 0 0 R

66600 $ 1,526.22 $ 1,526.22 90 10% 70% 20% 0 2 1 1 0 0 R

66605 $ 1,931.02 $ 1,931.02 90 10% 70% 20% 0 2 1 1 0 0 R

66625 $ 786.20 $ 786.20 90 10% 70% 20% 0 2 1 1 0 0 R

66630 $ 1,042.99 $ 1,042.99 90 10% 70% 20% 0 2 1 1 0 0 R

66635 $ 1,051.85 $ 1,051.85 90 10% 70% 20% 0 2 1 1 0 0 R

66680 $ 949.38 $ 949.38 90 10% 70% 20% 0 2 1 1 1 0 R

66682 $ 1,170.76 $ 1,170.76 90 10% 70% 20% 0 2 1 1 0 0 R

66700 $ 826.05 $ 719.79 90 10% 70% 20% 0 2 1 0 0 0 R

66710 $ 805.81 $ 719.15 90 10% 70% 20% 0 2 1 1 0 0 R

66711 $ 1,178.98 $ 1,178.98 90 10% 70% 20% 0 3 1 1 0 0 66710 R

66720 $ 846.29 $ 751.41 90 10% 70% 20% 0 2 1 1 0 0 R

66740 $ 800.75 $ 719.15 90 10% 70% 20% 0 2 1 1 0 0 R

66761 $ 544.58 $ 432.00 10 10% 80% 10% 0 2 1 1 0 0 R

66762 $ 871.59 $ 781.77 90 10% 70% 20% 0 2 1 1 0 0 R

66770 $ 967.73 $ 886.77 90 10% 70% 20% 0 2 1 1 0 0 R

66820 $ 725.48 $ 725.48 90 10% 70% 20% 0 2 1 1 0 0 R

66821 $ 606.57 $ 571.78 90 10% 70% 20% 0 2 1 1 0 0 R

66825 $ 1,393.40 $ 1,393.40 90 10% 70% 20% 0 2 1 0 0 0 R

66830 $ 1,304.85 $ 1,304.85 90 10% 70% 20% 0 2 1 1 0 0 R

66840 $ 1,273.86 $ 1,273.86 90 10% 70% 20% 0 2 1 1 0 0 R

66850 $ 1,450.32 $ 1,450.32 90 10% 70% 20% 0 2 1 1 0 0 R

66852 $ 1,543.30 $ 1,543.30 90 10% 70% 20% 0 2 1 0 1 0 R

66920 $ 1,379.48 $ 1,379.48 90 10% 70% 20% 0 2 1 0 1 0 R

66930 $ 1,563.54 $ 1,563.54 90 10% 70% 20% 0 2 1 0 0 0 R

66940 $ 1,431.35 $ 1,431.35 90 10% 70% 20% 0 2 1 0 1 0 R

66982 $ 1,452.22 $ 1,452.22 90 10% 70% 20% 0 2 1 1 0 0 R

66983 $ 1,356.71 $ 1,356.71 90 10% 70% 20% 0 2 1 1 0 0 R

66984 $ 1,170.76 $ 1,170.76 90 10% 70% 20% 0 2 1 1 0 0 R

66985 $ 1,409.84 $ 1,409.84 90 10% 70% 20% 0 2 1 1 1 0 R

66986 $ 1,661.58 $ 1,661.58 90 10% 70% 20% 0 2 1 1 1 0 R

66990 $ 164.45 $ 164.45 0 0% 0% 0% 0 0 0 1 0 0 R


67005 $ 865.89 $ 865.89 90 10% 70% 20% 0 2 1 1 1 0 R

67010 $ 993.03 $ 993.03 90 10% 70% 20% 0 2 1 1 1 0 R

67015 $ 1,063.23 $ 1,063.23 90 10% 70% 20% 0 2 1 1 1 0 R

67025 $ 1,332.05 $ 1,158.11 90 10% 70% 20% 0 2 1 1 1 0 R

67027 $ 1,557.85 $ 1,557.85 90 10% 70% 20% 0 2 1 2 1 0 R Y

67028 $ 185.96 $ 183.43 0 0% 0% 0% 0 2 1 1 0 0 R

67030 $ 977.21 $ 977.21 90 10% 70% 20% 0 2 1 1 1 0 R

67031 $ 712.83 $ 653.37 90 10% 70% 20% 0 2 1 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


67036 $ 1,647.66 $ 1,647.66 90 10% 70% 20% 0 2 1 2 1 0 R

67039 $ 1,764.68 $ 1,764.68 90 10% 70% 20% 0 2 1 2 1 0 R

67040 $ 1,906.36 $ 1,906.36 90 10% 70% 20% 0 2 1 2 1 0 R

67041 $ 2,103.06 $ 2,103.06 90 10% 70% 20% 0 2 1 2 1 0 R

67042 $ 2,104.96 $ 2,104.96 90 10% 70% 20% 0 2 1 2 1 0 R

67043 $ 2,221.97 $ 2,221.97 90 10% 70% 20% 0 2 1 2 1 0 R

67101 $ 602.77 $ 522.45 90 10% 70% 20% 0 2 1 1 0 0 R

67105 $ 544.58 $ 504.74 90 10% 70% 20% 0 2 1 1 0 0 R

67107 $ 2,068.28 $ 2,068.28 90 10% 70% 20% 0 2 1 2 1 0 R

67108 $ 2,192.88 $ 2,192.88 90 10% 70% 20% 0 2 1 2 1 0 R

67110 $ 1,607.82 $ 1,489.54 90 10% 70% 20% 0 2 1 1 0 0 R

67113 $ 2,447.14 $ 2,447.14 90 10% 70% 20% 0 2 1 2 1 0 R

67115 $ 916.49 $ 916.49 90 10% 70% 20% 0 2 1 1 0 0 R

67120 $ 1,207.44 $ 1,022.12 90 10% 70% 20% 0 2 1 1 1 0 R

67121 $ 1,660.95 $ 1,660.95 90 10% 70% 20% 0 2 1 2 1 0 R

67141 $ 960.14 $ 893.72 90 10% 70% 20% 0 2 1 1 0 0 R

67145 $ 965.20 $ 912.70 90 10% 70% 20% 0 2 1 1 0 0 R

67208 $ 1,096.76 $ 1,058.17 90 10% 70% 20% 0 2 1 1 0 0 R

67210 $ 950.02 $ 917.13 90 10% 70% 20% 0 2 1 1 0 0 R


67220 $ 979.11 $ 917.13 90 10% 70% 20% 0 2 1 1 0 0 R Y



67227 $ 531.30 $ 469.95 90 10% 70% 20% 0 2 1 1 0 0 R Y

67228 $ 623.01 $ 561.03 90 10% 70% 20% 0 2 1 1 0 0 R Y


67250 $ 1,430.08 $ 1,430.08 90 10% 70% 20% 0 2 1 1 1 0 R

67255 $ 1,252.98 $ 1,252.98 90 10% 70% 20% 0 2 1 2 1 0 R


67311 $ 1,093.59 $ 1,093.59 90 10% 70% 20% 0 2 1 1 0 0 R Y

67312 $ 1,301.05 $ 1,301.05 90 10% 70% 20% 0 2 1 1 1 0 R Y

67314 $ 1,230.85 $ 1,230.85 90 10% 70% 20% 0 2 1 1 0 0 R Y

67316 $ 1,464.87 $ 1,464.87 90 10% 70% 20% 0 2 1 0 0 0 R Y

67318 $ 1,291.57 $ 1,291.57 90 10% 70% 20% 0 2 1 1 1 0 R Y

67320 $ 586.33 $ 586.33 0 0% 0% 0% 0 0 0 1 0 0 R Y

67331 $ 557.23 $ 557.23 0 0% 0% 0% 0 0 1 1 1 0 R Y

67332 $ 604.67 $ 604.67 0 0% 0% 0% 0 0 1 1 1 0 R Y

67334 $ 549.01 $ 549.01 0 0% 0% 0% 0 0 1 1 1 0 R Y

67335 $ 270.71 $ 270.71 0 0% 0% 0% 0 0 1 1 1 0 R Y

67340 $ 652.74 $ 652.74 0 0% 0% 0% 0 0 0 2 0 0 R Y

67343 $ 1,196.69 $ 1,196.69 90 10% 70% 20% 0 2 1 1 1 0 R

67345 $ 440.22 $ 395.95 10 10% 80% 10% 0 2 1 1 0 0 R Y

67346 $ 354.20 $ 354.20 0 0% 0% 0% 0 2 1 0 0 0 R Y


67400 $ 1,703.96 $ 1,703.96 90 10% 70% 20% 0 2 1 1 1 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


67405 $ 1,450.96 $ 1,450.96 90 10% 70% 20% 0 2 1 1 0 0 R

67412 $ 1,558.48 $ 1,558.48 90 10% 70% 20% 0 2 1 1 1 0 R

67413 $ 1,565.44 $ 1,565.44 90 10% 70% 20% 0 2 1 2 0 0 R

67414 $ 2,422.48 $ 2,422.48 90 10% 70% 20% 0 2 1 2 1 0 R


67420 $ 2,952.51 $ 2,952.51 90 10% 70% 20% 0 2 1 2 1 0 R

67430 $ 2,262.45 $ 2,262.45 90 10% 70% 20% 0 2 1 2 0 0 R

67440 $ 2,208.69 $ 2,208.69 90 10% 70% 20% 0 2 1 2 1 0 R

67445 $ 2,559.73 $ 2,559.73 90 10% 70% 20% 0 2 1 2 1 0 R

67450 $ 2,287.12 $ 2,287.12 90 10% 70% 20% 0 2 1 2 1 0 R

67500 $ 141.05 $ 129.03 0 0% 0% 0% 0 2 1 1 0 0 R

67505 $ 161.29 $ 147.37 0 0% 0% 0% 0 2 1 1 0 0 R

67515 $ 177.10 $ 163.19 0 0% 0% 0% 0 2 1 1 0 0 R

67550 $ 1,765.94 $ 1,765.94 90 10% 70% 20% 0 2 1 1 1 0 R

67560 $ 1,808.95 $ 1,808.95 90 10% 70% 20% 0 2 1 0 0 0 R

67570 $ 2,119.51 $ 2,119.51 90 10% 70% 20% 0 2 1 2 1 0 R


67700 $ 497.15 $ 213.15 10 10% 80% 10% 0 2 1 1 0 0 R

67710 $ 414.29 $ 178.37 10 10% 80% 10% 0 2 1 1 0 0 R

67715 $ 443.38 $ 197.97 10 10% 80% 10% 0 2 1 1 0 0 R

67800 $ 232.13 $ 189.75 10 10% 80% 10% 0 2 0 1 0 0 R

67801 $ 296.64 $ 243.51 10 10% 80% 10% 0 2 0 1 0 0 R

67805 $ 368.75 $ 301.07 10 10% 80% 10% 0 2 0 1 0 0 R

67808 $ 674.25 $ 674.25 90 10% 70% 20% 0 2 0 1 0 0 R

67810 $ 318.15 $ 130.30 0 0% 0% 0% 0 2 1 1 0 0 R Y

67820 $ 91.71 $ 97.41 0 0% 0% 0% 0 2 1 1 0 0 R

67825 $ 235.29 $ 222.64 10 10% 80% 10% 0 2 1 1 0 0 R

67830 $ 491.45 $ 252.37 10 10% 80% 10% 0 2 1 1 0 0 R

67835 $ 803.91 $ 803.91 90 10% 70% 20% 0 2 1 0 0 0 R

67840 $ 507.90 $ 289.69 10 10% 80% 10% 0 2 1 1 0 0 R

67850 $ 395.95 $ 248.57 10 10% 80% 10% 0 2 1 1 0 0 R

67875 $ 316.25 $ 178.37 0 0% 0% 0% 0 2 1 1 0 0 R

67880 $ 841.86 $ 675.51 90 10% 70% 20% 0 2 1 1 0 0 R

67882 $ 1,034.77 $ 865.26 90 10% 70% 20% 0 2 1 1 0 0 R

67900 $ 1,173.92 $ 931.04 90 10% 70% 20% 0 2 1 1 0 0 R

67901 $ 1,390.24 $ 1,055.64 90 10% 70% 20% 0 2 1 1 0 0 R

67902 $ 1,320.66 $ 1,320.66 90 10% 70% 20% 0 2 1 1 1 0 R

67903 $ 1,087.90 $ 884.87 90 10% 70% 20% 0 2 1 1 1 0 R

67904 $ 1,343.43 $ 1,092.96 90 10% 70% 20% 0 2 1 1 1 0 R

67906 $ 929.78 $ 929.78 90 10% 70% 20% 0 2 1 1 0 0 R

67908 $ 905.11 $ 777.98 90 10% 70% 20% 0 2 1 1 0 0 R

67909 $ 984.17 $ 803.28 90 10% 70% 20% 0 2 1 1 0 0 R

67911 $ 1,029.08 $ 1,029.08 90 10% 70% 20% 0 2 1 1 0 0 R

67912 $ 1,623.63 $ 894.36 90 10% 70% 20% 0 2 1 1 0 0 R

67914 $ 866.53 $ 601.51 90 10% 70% 20% 0 2 1 1 0 0 R



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


67915 $ 540.16 $ 364.32 90 10% 70% 20% 0 2 1 1 0 0 R

67916 $ 1,089.17 $ 789.99 90 10% 70% 20% 0 2 1 1 0 0 R

67917 $ 1,107.51 $ 838.70 90 10% 70% 20% 0 2 1 1 0 0 R

67921 $ 849.45 $ 570.52 90 10% 70% 20% 0 2 1 1 0 0 R

67922 $ 535.10 $ 364.32 90 10% 70% 20% 0 2 1 1 0 0 R

67923 $ 1,087.90 $ 789.36 90 10% 70% 20% 0 2 1 1 0 0 R

67924 $ 1,159.37 $ 839.33 90 10% 70% 20% 0 2 1 1 0 0 R

67930 $ 669.19 $ 438.32 10 10% 80% 10% 0 2 1 1 0 0 R

67935 $ 1,089.17 $ 806.44 90 10% 70% 20% 0 2 1 1 0 0 R

67938 $ 452.24 $ 213.79 10 10% 80% 10% 0 2 1 1 0 0 R

67950 $ 1,050.58 $ 848.82 90 10% 70% 20% 0 2 1 1 1 0 R

67961 $ 1,055.64 $ 833.64 90 10% 70% 20% 0 2 1 0 0 0 R

67966 $ 1,406.68 $ 1,201.75 90 10% 70% 20% 0 2 1 1 0 0 R

67971 $ 1,322.56 $ 1,322.56 90 10% 70% 20% 0 2 1 1 1 0 R

67973 $ 1,700.16 $ 1,700.16 90 10% 70% 20% 0 2 1 2 1 0 R

67974 $ 1,696.37 $ 1,696.37 90 10% 70% 20% 0 2 1 2 1 0 R

67975 $ 1,251.09 $ 1,251.09 90 10% 70% 20% 0 2 1 1 0 0 R


68020 $ 218.85 $ 202.40 10 10% 80% 10% 0 2 1 1 0 0 R Y


68100 $ 313.09 $ 178.37 0 0% 0% 0% 0 2 1 1 0 0 R Y

68110 $ 415.55 $ 272.61 10 10% 80% 10% 0 2 1 1 0 0 R

68115 $ 574.31 $ 337.12 10 10% 80% 10% 0 2 1 1 0 0 R

68130 $ 990.50 $ 755.21 90 10% 70% 20% 0 2 1 1 0 0 R

68135 $ 286.52 $ 276.40 10 10% 80% 10% 0 2 1 1 0 0 R

68200 $ 75.90 $ 63.88 0 0% 0% 0% 0 2 1 1 0 0 R

68320 $ 1,333.31 $ 988.60 90 10% 70% 20% 0 2 1 1 1 0 R

68325 $ 1,205.55 $ 1,205.55 90 10% 70% 20% 0 2 1 1 1 0 R

68326 $ 1,182.78 $ 1,182.78 90 10% 70% 20% 0 2 1 1 0 0 R

68328 $ 1,296.63 $ 1,296.63 90 10% 70% 20% 0 2 1 0 0 0 R

68330 $ 1,111.30 $ 845.65 90 10% 70% 20% 0 2 1 0 0 0 R

68335 $ 1,187.20 $ 1,187.20 90 10% 70% 20% 0 2 1 1 1 0 R

68340 $ 1,002.51 $ 731.80 90 10% 70% 20% 0 2 1 0 0 0 R

68360 $ 977.85 $ 755.21 90 10% 70% 20% 0 2 1 1 0 0 R

68362 $ 1,201.75 $ 1,201.75 90 10% 70% 20% 0 2 1 1 1 0 R

68371 $ 757.74 $ 757.74 10 10% 80% 10% 0 2 1 1 0 0 R


68400 $ 525.61 $ 241.62 10 10% 80% 10% 0 2 1 1 0 0 R Y

68420 $ 592.02 $ 307.40 10 10% 80% 10% 0 2 1 1 0 0 R Y

68440 $ 187.22 $ 182.16 10 10% 80% 10% 0 2 1 1 0 0 R Y

68500 $ 1,789.34 $ 1,789.34 90 10% 70% 20% 0 2 1 1 0 0 R Y

68505 $ 1,772.90 $ 1,772.90 90 10% 70% 20% 0 2 1 1 0 0 R Y

68510 $ 815.93 $ 531.30 0 0% 0% 0% 0 2 1 0 0 0 R Y

68520 $ 1,256.78 $ 1,256.78 90 10% 70% 20% 0 2 1 0 0 0 R Y

68525 $ 480.70 $ 480.70 0 0% 0% 0% 0 2 1 1 1 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


68530 $ 786.83 $ 470.58 10 10% 80% 10% 0 2 1 1 0 0 R Y



68700 $ 1,105.61 $ 1,105.61 90 10% 70% 20% 0 2 1 1 0 0 R

68705 $ 435.79 $ 304.87 10 10% 80% 10% 0 2 1 1 0 0 R

68720 $ 1,384.54 $ 1,384.54 90 10% 70% 20% 0 2 1 2 1 0 R

68745 $ 1,390.87 $ 1,390.87 90 10% 70% 20% 0 2 1 2 1 0 R

68750 $ 1,439.57 $ 1,439.57 90 10% 70% 20% 0 2 1 2 1 0 R

68760 $ 370.65 $ 268.18 10 10% 80% 10% 0 2 1 1 0 0 R

68761 $ 271.98 $ 218.21 10 10% 80% 10% 0 2 1 0 0 0 R

68770 $ 1,152.42 $ 1,152.42 90 10% 70% 20% 0 2 1 0 0 0 R

68801 $ 163.19 $ 146.11 10 10% 80% 10% 0 2 1 1 0 0 R

68810 $ 289.69 $ 234.66 10 10% 80% 10% 0 2 1 1 0 0 R

68811 $ 249.84 $ 249.84 10 10% 80% 10% 0 2 1 1 0 0 R

68815 $ 734.97 $ 406.70 10 10% 80% 10% 0 2 1 1 0 0 R

68816 $ 1,203.65 $ 299.17 10 10% 80% 10% 0 2 1 1 0 0 R

68840 $ 234.66 $ 214.42 10 10% 80% 10% 0 2 1 1 0 0 R

68850 $ 112.59 $ 103.73 0 0% 0% 0% 0 2 1 1 0 0 R


69000 $ 345.98 $ 218.21 10 10% 80% 10% 0 2 1 1 0 0 R

69005 $ 393.42 $ 285.26 10 10% 80% 10% 0 2 1 1 0 0 R

69020 $ 429.47 $ 261.22 10 10% 80% 10% 0 2 1 1 0 0 R


69100 $ 185.96 $ 89.18 0 0% 0% 0% 0 2 0 1 0 0 R Y

69105 $ 259.33 $ 116.38 0 0% 0% 0% 0 2 1 1 0 0 R Y

69110 $ 846.29 $ 595.82 90 7% 79% 14% 0 2 1 1 0 0 R

69120 $ 748.88 $ 748.88 90 7% 79% 14% 0 2 0 1 0 0 R

69140 $ 1,616.04 $ 1,616.04 90 7% 79% 14% 0 2 1 0 0 0 R

69145 $ 732.44 $ 457.93 90 7% 79% 14% 0 2 1 1 0 0 R



69200 $ 152.43 $ 86.02 0 0% 0% 0% 0 2 1 1 0 0 R

69205 $ 185.96 $ 185.96 10 10% 80% 10% 0 2 1 1 0 0 R

69209 $ 24.04 $ 24.04 0 0% 0% 0% 5 2 1 1 0 0 R Y

69210 $ 89.18 $ 59.46 0 0% 0% 0% 0 2 2 1 0 0 R

69220 $ 165.72 $ 93.61 0 0% 0% 0% 0 2 1 1 0 0 R

69222 $ 405.43 $ 251.10 10 10% 80% 10% 0 2 1 1 0 0 R


69310 $ 2,008.19 $ 2,008.19 90 7% 79% 14% 0 2 1 1 0 0 R



69420 $ 352.94 $ 220.74 10 10% 80% 10% 0 2 1 1 0 0 R Y

69421 $ 271.98 $ 271.98 10 10% 80% 10% 0 2 1 1 0 0 R Y

69424 $ 235.29 $ 113.22 0 0% 0% 0% 0 2 1 1 0 0 R Y

69433 $ 373.18 $ 242.25 10 10% 80% 10% 0 2 1 1 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


69436 $ 292.85 $ 292.85 10 10% 80% 10% 0 2 1 1 0 0 R Y

69440 $ 1,263.74 $ 1,263.74 90 7% 79% 14% 0 2 1 1 0 0 R

69450 $ 1,001.88 $ 1,001.88 90 7% 79% 14% 0 2 1 0 0 0 R

69501 $ 1,341.53 $ 1,341.53 90 7% 79% 14% 0 2 1 1 0 0 R Y

69502 $ 1,781.75 $ 1,781.75 90 7% 79% 14% 0 2 1 0 0 0 R Y

69505 $ 2,211.22 $ 2,211.22 90 7% 79% 14% 0 2 1 0 0 0 R Y

69511 $ 2,265.62 $ 2,265.62 90 7% 79% 14% 0 2 1 0 0 0 R Y

69530 $ 3,053.71 $ 3,053.71 90 7% 79% 14% 0 2 1 2 0 0 R Y






69601 $ 1,911.42 $ 1,911.42 90 7% 79% 14% 0 2 1 0 0 0 R Y

69602 $ 1,996.17 $ 1,996.17 90 7% 79% 14% 0 2 1 0 0 0 R Y

69603 $ 2,325.70 $ 2,325.70 90 7% 79% 14% 0 2 1 0 0 0 R Y

69604 $ 2,032.22 $ 2,032.22 90 7% 79% 14% 0 2 1 1 0 0 R Y

69605 $ 3,054.34 $ 3,054.34 90 7% 79% 14% 0 2 1 2 0 0 R Y

69610 $ 700.81 $ 528.14 10 10% 80% 10% 0 2 1 1 0 0 R

69620 $ 1,276.39 $ 893.72 90 7% 79% 14% 0 2 1 1 0 0 R

69631 $ 1,621.73 $ 1,621.73 90 7% 79% 14% 0 2 1 1 0 0 R

69632 $ 1,974.03 $ 1,974.03 90 7% 79% 14% 0 2 1 1 0 0 R

69633 $ 1,913.95 $ 1,913.95 90 7% 79% 14% 0 2 1 1 0 0 R

69635 $ 2,269.41 $ 2,269.41 90 7% 79% 14% 0 2 1 1 0 0 R

69636 $ 2,533.80 $ 2,533.80 90 7% 79% 14% 0 2 1 0 0 0 R

69637 $ 2,568.58 $ 2,568.58 90 7% 79% 14% 0 2 1 0 0 0 R

69641 $ 1,905.09 $ 1,905.09 90 7% 79% 14% 0 2 1 1 0 0 R Y

69642 $ 2,440.82 $ 2,440.82 90 7% 79% 14% 0 2 1 1 0 0 R Y

69643 $ 2,235.89 $ 2,235.89 90 7% 79% 14% 0 2 1 1 0 0 R Y

69644 $ 2,710.26 $ 2,710.26 90 7% 79% 14% 0 2 1 1 0 0 R Y

69645 $ 2,665.36 $ 2,665.36 90 7% 79% 14% 0 2 1 1 0 0 R Y

69646 $ 2,827.91 $ 2,827.91 90 7% 79% 14% 0 2 1 0 0 0 R Y

69650 $ 1,476.89 $ 1,476.89 90 7% 79% 14% 0 2 1 1 0 0 R

69660 $ 1,691.94 $ 1,691.94 90 7% 79% 14% 0 2 1 1 0 0 R

69661 $ 2,201.10 $ 2,201.10 90 7% 79% 14% 0 2 1 0 0 0 R

69662 $ 2,117.61 $ 2,117.61 90 7% 79% 14% 0 2 1 1 0 0 R

69666 $ 1,487.01 $ 1,487.01 90 7% 79% 14% 0 2 1 0 0 0 R

69667 $ 1,486.38 $ 1,486.38 90 7% 79% 14% 0 2 1 0 0 0 R

69670 $ 1,737.48 $ 1,737.48 90 7% 79% 14% 0 2 1 2 0 0 R Y

69676 $ 1,523.06 $ 1,523.06 90 7% 79% 14% 0 2 1 1 0 0 R Y

69700 $ 1,270.69 $ 1,270.69 90 7% 79% 14% 0 2 1 1 0 0 R


69711 $ 1,577.46 $ 1,577.46 90 7% 79% 14% 0 2 1 2 0 0 R Y

69714 $ 1,967.08 $ 1,967.08 90 7% 79% 14% 0 2 1 1 0 0 R Y

69715 $ 2,500.91 $ 2,500.91 90 7% 79% 14% 0 2 1 1 0 0 R Y



Surgery


CPT

CODE FOL UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH


NON-FACILITY


69717 $ 2,066.38 $ 2,066.38 90 7% 79% 14% 0 2 1 1 0 0 R Y

69718 $ 2,443.98 $ 2,443.98 90 7% 79% 14% 0 2 1 1 0 0 R Y

69720 $ 2,220.08 $ 2,220.08 90 7% 79% 14% 0 2 1 0 1 0 R

69725 $ 3,419.93 $ 3,419.93 90 7% 79% 14% 0 2 1 2 0 0 R

69740 $ 2,166.31 $ 2,166.31 90 7% 79% 14% 0 2 1 2 0 0 R

69745 $ 2,147.97 $ 2,147.97 90 7% 79% 14% 0 2 1 2 0 0 R


69801 $ 358.00 $ 228.33 0 0% 0% 0% 0 2 1 0 0 0 R Y

69805 $ 1,920.90 $ 1,920.90 90 7% 79% 14% 0 2 1 2 0 0 R Y

69806 $ 1,725.46 $ 1,725.46 90 7% 79% 14% 0 2 1 1 0 0 R Y

69820 $ 1,532.55 $ 1,532.55 90 7% 79% 14% 0 2 1 2 0 0 R Y

69840 $ 1,659.68 $ 1,659.68 90 7% 79% 14% 0 2 1 2 0 0 R Y

69905 $ 1,678.66 $ 1,678.66 90 7% 79% 14% 0 2 1 1 0 0 R Y

69910 $ 1,866.51 $ 1,866.51 90 7% 79% 14% 0 2 1 0 0 0 R Y

69915 $ 2,870.92 $ 2,870.92 90 7% 79% 14% 0 2 1 2 1 0 R Y

69930 $ 2,227.67 $ 2,227.67 90 7% 79% 14% 0 2 1 0 0 0 R Y-UR


69950 $ 3,280.78 $ 3,280.78 90 7% 79% 14% 0 2 1 2 1 0 R Y

69955 $ 3,589.44 $ 3,589.44 90 7% 79% 14% 0 2 1 2 1 0 R

69960 $ 3,497.09 $ 3,497.09 90 7% 79% 14% 0 2 1 2 1 0 R



69990 $ 387.72 $ 387.72 0 0% 0% 0% 0 0 0 2 0 0 R


Surgery Fee Schedule - Labor & Industries (L&I ... · Professional Services Fee Schedule Surgery...

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Transcript of Surgery Fee Schedule - Labor & Industries (L&I ... · Professional Services Fee Schedule Surgery...